SURAT RUJUKAN
No: ........./SBC/SR/........./20..
Yth ................
.......................
Di ..................
Mohon Pemeriksaan dan pengobatan lebih lanjut terhadap penderita
Nama Pasien : ................................................................................................................
Jenis Kelamin : ................................................................................................................
Umur : ................................................................................................................
No. Telepon : ................................................................................................................
Alamat Rumah : ................................................................................................................
......................................................................................................................................................
Anamnese
Keluhan : ................................................................................................................
Diagnosa sementara : ................................................................................................................
Kasus : ................................................................................................................
................................................................................................................
Terapi / Obat yang diberikan : ………………………………………………………………….
Demikian surat rujukan ini kami kirim, mohon balasan atas surat rujukan ini, Atas
perhatian Bapak / Ibu kami ucapkan Terimakasih.
Hormat kami,
(……………………………)