Fom Rujukan Internal.docx

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PEMERINTAH KABUPATEN BATANG HARI DINAS KESEHATAN PUSKESMAS MUARA BULIAN Jl. Jendral sudirman km 3 Muara Bulian Email: [email protected]

PEMERINTAH KABUPATEN BATANG HARI DINAS KESEHATAN PUSKESMAS MUARA BULIAN Jl. Jendral sudirman km 3 Muara Bulian Email: [email protected]

RUJUKAN INTERNAL No.RM………………………

RUJUKAN INTERNAL No.RM………………………

Kepada Yth

Kepada Yth

………………………………..

……………………..

Di Poli……………………..

Di Poli……………………..

Dengan ini kami mengirimkan pasien :

Dengan ini kami mengirimkan pasien : Nama

:……………………………………………………..............

Umur:……………………………………………………...............................

Umur

:……………………………………………………...............

Jenis Kelamin :

Jenis Kelamin :

Nama

:……………………………………………………............................

:……………………………………………………..............

Alamat :……………………………………………………...............

Diagnosa sementara :…………………………………………………...........

Diagnosa sementara:…………………………………………………

Telah kami berikan terapi :………………………………………………………………………............

Telah kami berikan terapi :………………………………………………………………………

Mohon di lakukan tindak lanjut di Poli……………………………………..

Mohon di lakukan tindak lanjut di Poli……………………………………..

Demikian atas perhatiannya kami ucapkan terimakasih

Demikian atas perhatiannya kami ucapkan terimakasih

Pengirim : poli .............................................................................................. Muara Bulian,……………..201..

Pengirim : poli ......................................................................................... Muara Bulian,……………201..

Alamat

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