61.surat Rujukan Rev 00.doc

RM.61

RUMAH SAKIT UMUM DAERAH CEMPAKA PUTIH Jl.Rawasari Selatan No.1 Jakarta Pusat Telp. (021) 4224243,Fax (021)‐42801340 [email protected]

Jakarta

SURAT RUJUKAN Kepada Yth ; RS ................................. .................................. Mohon dilakukan pemeriksaan / tatalaksana selanjutnya atas pasien : Nama

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Umur

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Jenis kelamin :

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Alamat

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Dengan Anamnesis

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......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Pemeriksaan fisik : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Pemeriksaan penunjang : ......................................................................................................................................................... ......................................................................................................................................................... Diagnosis : ......................................................................................................................................................... ......................................................................................................................................................... Alasan Rujuk : ............................................................................................................................................ ............. Tindakan / Pengobatan yang telah diberikan: ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Atas kerjasamanya, kami ucapkan terima kasih. Jakarta ,......................20............ Dokter yang memeriksa

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REV.00/FRJ/2016