PEMERINTAH KABUPATEN ACEH BARAT DAYA
PUSKESMAS MANGGENG
KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA
Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762
SURAT RUJUKAN PUSKESMAS
No. Rujukan
FKTP
Kabupaten
:
: Puskesmas Manggeng
: Aceh Barat Daya
Kepada Yth ;
TS,Poli dr
: ...........................................................
RSU
: ...........................................................
Mohon Pemeriksaan dan Penanganan lebih lanjut penderita :
Nama
: .............................................................................
No. Kartu BPJS
: .............................................................................
Tanggal Lahir / Umur
: .............................................................................
Jenis Kelamin
: .............................................................................
Alamat
: .............................................................................
..............................................................................
Keluhan
: ...............................................................................................................................
Diagnosa Sementara : ...............................................................................................................................
Telah diberikan
: ...............................................................................................................................
Demikian atas kerja sama yang baik teman sejawat kami ucapkan terima kasih.
Yang menerima rujukan ;
Pada tanggal ,.......................
Manggeng,............................................
Salam Sejawat,
(...........................................................)
NIP./ NRPTT.........................................
( [Link] FAKHRIZAL )
NIP. 19860402 201412 2 1 002
PEMERINTAH KABUPATEN ACEH BARAT DAYA
PUSKESMAS MANGGENG
KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA
Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762
SURAT RUJUKAN PUSKESMAS
No. Rujukan
FKTP
Kabupaten
:
: Puskesmas Manggeng
: Aceh Barat Daya
Kepada Yth ;
TS,Poli dr
: ...........................................................
RSU
: ...........................................................
Mohon Pemeriksaan dan Penanganan lebih lanjut penderita :
Nama
: .............................................................................
No. Kartu BPJS
: .............................................................................
Tanggal Lahir / Umur
: .............................................................................
Jenis Kelamin
: .............................................................................
Alamat
: .............................................................................
..............................................................................
Keluhan
: ...............................................................................................................................
Diagnosa Sementara : ...............................................................................................................................
Telah diberikan
: ...............................................................................................................................
Demikian atas kerja sama yang baik teman sejawat kami ucapkan terima kasih.
Yang menerima rujukan ;
Pada tanggal ,.......................
Manggeng,............................................
Salam Sejawat,
(...........................................................)
NIP./ NRPTT.........................................
( [Link] ARFINA )
NIP. 19820320 200804 2 001
PEMERINTAH KABUPATEN ACEH BARAT DAYA
PUSKESMAS MANGGENG
KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA
Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762
SURAT KETERANGAN MEDIS
NAMA
: ...........................................................................................................................................
NO. IDENTITAS
: ...........................................................................................................................................
ALAMAT
: ...........................................................................................................................................
KELUHAN
: ...........................................................................................................................................
...........................................................................................................................................
DIAGNOSA
: ...........................................................................................................................................
THERAPY
: ...........................................................................................................................................
MENERANGKAN KONDISI :
.................................................................................................................................................................................
.................................................................................................................................................................................
Manggeng,............................................
Dokter Yang Menangani
( [Link] ARFINA )
NIP. 19820320 200804 2 001
PEMERINTAH KABUPATEN ACEH BARAT DAYA
PUSKESMAS MANGGENG
KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA
Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762
SURAT KETERANGAN MEDIS
NAMA
: ...........................................................................................................................................
NO. IDENTITAS
: ...........................................................................................................................................
ALAMAT
: ...........................................................................................................................................
KELUHAN
: ...........................................................................................................................................
...........................................................................................................................................
DIAGNOSA
: ...........................................................................................................................................
THERAPY
: ...........................................................................................................................................
MENERANGKAN KONDISI :
.................................................................................................................................................................................
.................................................................................................................................................................................
Manggeng,............................................
Dokter Yang Menangani
( [Link] FAKHRIZAL )
NIP. 19860402 201412 2 1 002