SURAT RUJUKAN
KLINIK PRATAMA PHALA MEDIKA
Nomor :…………………………………………… Kepada Yth
Number
To
Lampiran :
Ts. dr
……………………………………………
Enclosure ..
Perihal : .............................................. di_
Subject at
Dengan hormat,
To whom it my concern
Bersama ini kami rujuk/pindah rawat pasien atas nama :
Here we refer /transfer patient as below
Nama : …….. .............................................................................................
Name
Tgl Lahir/Umur : .....................................................................................................
Date of birth/age
Pekerjaan : ....................................................................................................
Occupation
Alamat : ...................................................................................................
Address
Diagnosis : .....................................................................................................
Diagnose
Terapi :…....................................................................................................
Therapy
Alasan : ...................................................................................................
Reason
Konfirmasi RS : □ ya /yes □ tidak /no, petugas yang dihubungi : ...................................
dituju Contact person
Comfirmation of ………,.............................
referred Hormat kami/ yours sincerely
/ transfered hospital
Catatan lainnya :
(dr. )