KLINIK AULIA
Jalan Raya PELDA BUNAWAR No.74 PUALAM SARI [Link].087859171677
KECAMATAN BINUANG Kode Pos: 71183
SURAT RUJUKAN
Kepada Yth
TS Bagian : ....................................
Di Tempat
Mohon tindakan selanjutnya untuk pasien :
Nama : .....................................................................................................
Umur : .....................................................................................................
Alamat : .....................................................................................................
Pemeriksaan Awal ......................................................................................................:
......................................................................................................
......................................................................................................
Diagnosis : .....................................................................................................
......................................................................................................
Tatalaksana Awal : .....................................................................................................
......................................................................................................
.......................................................................................................
Atas kerjasamanya terimakasih.
Tapin, ……… / …………………….. / 20…..
Dokter Pemeriksa
(___________________________)