PT.

Askes (Persero)
Kantor Regional / Kantor Cabang : REGIONAL VII - SURABAYA / KEDIRI

Rujukan Puskesmas / Dokter Keluarga

SURAT RUJUKAN PESERTA
No. Rujukan

.............................................

Puskesmas/Dokter Keluarga

......................................................

Kode :

.........................

Kabupaten/Kota

.....................................................

Kode :

........................

Kepada Yth. TS dr. Poli

: ................................................................................

Di RSU

: ................................................................................

Mohon pemeriksaan dan penanganan lebih lanjut penderita :

Nama

: ...................................................

Umur :

No. Kartu BPJS

: .....................................................

Status :

Diagnosa

: ....................................................

Telah diberikan

.........

Tahun

....................
P

Utama/ Tanggungan

(L/P)

Demikian atas bantuannya, diucapkan banyak terima kasih

Salam sejawat,

...................... 2014

dr.............................

SURAT RUJUKAN BALIK

Teman sejawat Yth.
Mohon kontrol selanjutnya penderita :
Nama

: .........................................................................................................................................

Diagnosa

: .........................................................................................................................................

Terapi

: .........................................................................................................................................

Tindak lanjut yang dianjurkan

Pengobatan dengan obat-obatan :

Perlu rawat inap

.............................................................................

Konsultasi selesai

Kontrol kembali ke RS tanggal : .........................

Lain-lain : ............................................................

................................ tgl .......................................

Dokter RS,

(..........................................................)