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SURAT RUJUKAN PEMERIKSAAN KESEHATAN

NOMOR :

Kepada Yth.
Sejawat Dokter Pemeriksa Kesehatan Jemaah Haji
RS.................................................

Dengan ini kami kirimkan jemaah haji :


Nama :..........................................................................................
Jenis Kelamin :..........................................................................................
Alamat Tinggal :..........................................................................................
..........................................................................................
Kab/Kota...........................................................................
Diagnosis :..........................................................................................
...........................................................................................
...........................................................................................
Untuk dilakukan pemeriksaan dan penatalaksanaan lebih lanjut.
Terapi yang sudah diberikan......................................................................................
...................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Tangerang, 20
Pemeriksa Kesehatan Jemaah Haji
Puskesmas Pabuaran Tumpeng

dr.....................................................
NIP/SIP

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