Praktek:
Rukan kencana niaga Blok D1/2N
Jl. Aries Utama IV No.7, RT.12/RW.8,
Meruya Utara, Kec. Kembangan, Jakarta Barat 11620
Telp: 0878-8756-6315
SURAT RUJUKAN
Jakarta, ...............2022
Kepada Yth
Ts :
RS :
Dengan hormat,
Mohon perawatan lebih klanjut penderita tersebut di bawah ini :
Nama :
Umur :
Jenis Kelamin :
Alamat :
Anamesa :
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Pemeriksaan fisik :
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Diagnosa sementara :
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Terapi/ obat yang telah diberikan :
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Alasan dirujuk:
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Dokter Penanggung Jawab
Dr. Tony Sukentro, Sp.B