Rumah sakit ibu dan anak

Yasmin
Jl CILIK RIWUT KM 1,5 NO 04 Telp 0536-3226193 fax 0536-3220734
Palangkaraya

Surat rujukan
Nomor :

Kepada Yth
Ts......................................
..........................................
Di.......................................
Denga hormat .
Dengan ini kami dikirim pasien untuk penanganan lebih lanjut terhadap:
Nama :
Umur :
Jenis kelamin :

Alamat : ..........................................................................................
.................................................

Anemnesi : ..........................................................................................
................................................
Pemeriksaan
fisik :....................................................................................................
........................................
......................................................................................................................
............................................................Diagnosis :
DD
Tela diterapi :
Laboratorium :

Palangkaraya, ..........................20........
Dokter
yang merawat,

(dr...............................................................)