KLINIK MANAR MEDIKA
IZIN NO : 445.4/0002/SIKPRJ/DPMPTSP/I/2018
Jl. Limo Raya Rt02/02 Kel. Limo [Link] Depok
Telp 021549795
SURAT RUJUKAN
Kepada Yth.
TS dr. ..........................
Di Tempat
Assalamualaikum WrWb
Dengan Hormat,
Mohon konsul/Keperawatan/Tindakan lanjut pada pasien :
Nama : ................................................................................................
Umur : ................................................................................................
Alamat :
................................................................................................
Pada pemeriksaan kami dapatkan :
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.......................................................................................................................................
Diagnosa sementara :
....................................................................................................
Terapi/Tindakan yang telah diberikan :
.......................................................................................................................................
.......................................................................................................................................
Atas bantuannya kami ucapkan terima kasih.
Hormat kami,
Dokter yang memeriksa :
(..........................................)