SURAT RUJUKAN
Yth : ......................................................................................................................................
Di Puskesmas : ......................................................................................................................................
Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita
Nama Pasien : ......................................................................................................................................
Jenis kelamin : ......................................................................................................................................
Umur : ......................................................................................................................................
Alamat Rumah : ......................................................................................................................................
Anamnesa
Keluhan :
....................................................................................................................................................................
................................................................................................................................................................
Therapi Obat
....................................................................................................................................................................
................................................................................................................................................................
Demikian surat rujukan ini kami kirim, kami mohon tindak lanjutnya
Girimukti,....................20.....
Pemeriksa
................................................
SURAT RUJUKAN
Yth : ......................................................................................................................................
Di Puskesmas : ......................................................................................................................................
Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita
Nama Pasien : ......................................................................................................................................
Jenis kelamin : ......................................................................................................................................
Umur : ......................................................................................................................................
Alamat Rumah : ......................................................................................................................................
Anamnesa
Keluhan :
....................................................................................................................................................................
................................................................................................................................................................
Therapi Obat
....................................................................................................................................................................
................................................................................................................................................................
Demikian surat rujukan ini kami kirim, kami mohon tindak lanjutnya
Girimukti,....................20.....
Pemeriksa
................................................