KLINIK AHSAN MEDIKA KLINIK AHSAN MEDIKA

Jl. Lintas Timur Desa Karya Makmur Ds. 1 Rt. 002/RW. 001 Jl. Lintas Timur Desa Karya Makmur Ds. 1 Rt. 002/RW. 001
Kec. Labuhan Maringgai Kab. Lampung Timur Kec. Labuhan Maringgai Kab. LampungTimur

SURAT RUJUKAN SURAT RUJUKAN

Kepada : .............................................................................. Kepada : ..............................................................................
Di RS : .............................................................................. Di RS : ..............................................................................

Mohon pemeriksaan dan pengobatan lebih lanjut, Mohon pemeriksaan dan pengobatan lebih lanjut,
Nama Pasien : .............................................................................. Nama Pasien : ..............................................................................
Jenis Kelamin : .............................................................................. Jenis Kelamin : ..............................................................................
Umur : .............................................................................. Umur : ..............................................................................
No. Telepon : .............................................................................. No. Telepon : ..............................................................................
Alamat : .............................................................................. Alamat : ..............................................................................
.............................................................................. ..............................................................................

Anamnesa Anamnesa
Keluhan : .............................................................................. Keluhan : ..............................................................................
.............................................................................. ..............................................................................
TTV : .............................................................................. TTV : ..............................................................................
.............................................................................. ..............................................................................
Diagnosa Sementara : .............................................................................. Diagnosa Sementara : ..............................................................................
Terapi : .............................................................................. Terapi : ..............................................................................
.............................................................................. ..............................................................................
.............................................................................. ..............................................................................

Demikian surat rujukan ini kami kirim, atas perhatiannya kami ucapkan Demikian surat rujukan ini kami kirim, atas perhatiannya kami ucapkan
terima kasih. terima kasih.
Karya Makmur, ................................... Karya Makmur, ...................................
Hormat Kami, Hormat Kami,