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PEMERINTAH KABUPATEN KUTAI TIMUR

PUSKESMAS MUARA WAHAU II KECAMATAN MUARA WAHAU Jalan Raya Wahau – Kongbeng Po Box 75655

SURAT RUJUKAN No : 445/

/ TU /

/ 2019

Kepada : Yth. RS………………………………. Bagian ………………………….. di – ……………………………..

Dengan hormat Yth, Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita :

Nama

: ………………………………………

Umur

: ……….. thn / bln

Jenis Kelamin

:L / P

Pekerjaan

: ………………………………………

Alamat

: ………………………………………

Diagnosa Sementara : ………………………………………………. ………………………………………………. Therapy

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

Hasil Laboratotium

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

PEMERINTAH KABUPATEN KUTAI TIMUR

PUSKESMAS MUARA WAHAU II KECAMATAN MUARA WAHAU Jalan Raya Wahau – Kongbeng Po Box 75655

Atas pertolongan diucapkan banyak terima kasih serta mohon informasi selanjutnya atas penderita tersebut.

Muara Wahau, Dokter Puskesmas Muara Wahau II

____________________________

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