PT.
NUSA LIMA MEDIKA
UNIT RUMAH SAKIT TANDUN
Desa Talang Danto, Kec. Tapung Hulu, Kab. Kampar – Riau 28464
SURAT RUJUKAN
Kepada Yth :
Poli / IGD .............................................
di RS .....................................................
Mohon pemeriksaan dan pengobatan lebih lanjut pasien :
Nama : ...................................................................... ( Tn/ Ny/ Nn/ An )
Tanggal Lahir : ......................................................................
Alamat : ......................................................................
Pembayaran : Pribadi / Asuransi / BPJS / Jaminan Perusahaan .................................
Dengan hasil pemeriksaan sementara sbb :
Anamnesa : ........................................................................................................................
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Pemeriksaan : ........................................................................................................................
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Diagnosa : ........................................................................................................................
Therapi & Tindakan yang sudah diberikan :
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Alat yang terpasang : .............................................................................................................
Kondisi saat di rujuk & Alasan Rujuk
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Kampar, 2024
Dokter
( ............................................ )