Surat Pengantar MRS

Kepada : Pertugas Admission National Hospital

Mohon perawatan pasien :

Nama :________________________________

Umur : _____________ L / P (lingkari)

Diagnose : _______________________________

Keluhan : _____________________________________

______________________________________________________

Pesanan setelah pasien MRS :

1. ___________________________________________________

2. _____________________________________________________

3. ______________________________________________________

Terima kasih,

Wassalam,

_________________________
Surat Pengantar Pemeriksaan /Tindakan

Kepada Yth : _____________________________

Mohon dilakukan pemeriksaan/tindakan :

1. ______________________________________

2. ______________________________________

Kepada pasien :

Nama :________________________________

Umur : _____________ L / P (lingkari)

Diagnose : _______________________________

Keluhan : _____________________________________

______________________________________________________

Hasil penunjang medik : ___________________________________

_________________________________________________________

Terima kasih.

Surabaya, ..............................2014

Wassalam,

_________________________