SURAT RUJUKAN

NO : / RSU-AII/ / 20

Yth. TS Dokter Ahli : .............................................................................................

Di : .............................................................................................
Mohon Pemeriksaan / Pengobatan Lebih Lanjut Terhadap Penderita :
Nama : .............................................................................................
Umur : .............................................................................................
Jenis Kelamin :(L/P)

Dengan Hasil Pemeriksaan Sementara Sbb.

1. Keterangan Medis : .............................................................................................
.............................................................................................
.............................................................................................
2. Diagnosa : .............................................................................................
3. Obat / Tindakan Yang Telah Diberikan : .................................................................
.................................................................
.................................................................
4. Alasan Pasien Dirujuk : .............................................................................................
Terima kasih atas bantuan T.S. dan kami harapkan jawaban rujukan ini

Kendari, ...........................20

Penerima Salam Sejawat,

(………………………...) (..........................................)