PEMERINTAH KABUPATEN SOLOK
DINAS KESEHATAN
PUSKESMAS SULIT AIR
KECAMATAN X KOTO DIATAS
Jl Balik Parit Sulit Air puskesmassulitair1@[Link]
SURAT RUJUKAN
No. /2019
Kepala Rumah Sakit,.......................................................................................................... ....................
Bagian........................................................................................................ ..............................................
TS Yth,
Mohon pemerIksaan dan pengobatan lebih lanjut terhadap penderita :
Nama : ................................................................................ .....................
Umur : ................................................................................ .....................
Kelamin : ....................................................................................................
No bpjs : ................................................................................ ....................
Dengan Diagnosa / keluhan : ............................................................................................... .....
Terima kasih, mohon informasi selanjutnya
Sulit Air .............................2019
Therapi yang telah dilakukan
......................................................................
......................................................................
..................................................................... [Link] PUTRI LOVITA
......................................................................
SURAT RUJUKAN BALIK
TS Yth, ......................................
Dikirim kembali penderita untuk tindak lanjut :
Nama : ----------------------------------------
Umur : ----------------------------------------
Kelamin : ----------------------------------------
Diagnosa : ----------------------------------------
Tindak lanjut yang dianjurkan :
[Link] : -----------------------------------------
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1. Kontrol kembali : -----------------------------------------
.......................Tgl................................
Dokter Pengirim
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