SURAT RUJUKAN
Kepada :
Yth, TS ......................................
Di RS
Mohon penatalaksanaan lanjutan terhadap pasien sbb :
Nama : ....................................................................................................
Umur : ....................................................................................................
Alamat : ....................................................................................................
Keluhan Utama : ....................................................................................................
Riwayat Penyakit Sekarang : ..................................................................................................
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Hasil Pemeriksaan Penunjang : ...............................................................................................
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Diagnosa : ....................................................................................................
Tindakan terapi : ....................................................................................................
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Indikasi di Rujuk : ....................................................................................................
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Mohon perawatan selanjutnya.
Tanjunganom, ..................................
( ............................................)