RUJUKAN INTERNAL
Tanggal............................................................................
UGD/PONED
Mohon untuk penatalaksanaan lebih lanjut, pasien :
Nama................................................................................ POLI UMUM
Umur........................ Jenis Kelamin................................
POLI GIGI
Keluhan............................................................................
Jenis pemeriksaan............................................................ POLI KIA/KB
Jenis Tindakan.................................................................
Diagnosa sementara......................................................... LABORATORIUM
Therapy :
KONSELING
......................................... Atas kerjasamanya terima
kasih
......................................... Dokter/petugas ruangan
NB : Beri Tanda
.............................
RUJUKAN INTERNAL
Tanggal............................................................................
UGD/PONED
Mohon untuk penatalaksanaan lebih lanjut, pasien :
Nama................................................................................ POLI UMUM
Umur........................ Jenis Kelamin................................
POLI GIGI
Keluhan............................................................................
Jenis pemeriksaan............................................................ POLI KIA/KB
Jenis Tindakan.................................................................
Diagnosa sementara......................................................... LABORATORIUM
Therapy :
KONSELING
......................................... Atas kerjasamanya terima
kasih
......................................... Dokter/petugas ruangan
NB : Beri Tanda
.............................