Rujuk Internal.docx
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PEMERINTAH KABUPATEN ACEH UTARA DINAS KESEHATAN
UPTD PUSKESMAS COT GIREK KECAMATAN COT GIREK Jln. Lhoksukon – Cot Girek, Batu XII Kode Pos 24383 Email : [email protected]. No Hp: 0823 6333 7828
FORMULIR RUJUKAN INTERNAL Nama Ruangan Pengirim
: .............................................................................................
Nama Ruangan ditiju
: ...........................................................................................
Nama Pasien
: ............................... Umur: ......... Tahun.
Jenis Kelamin: L/P
Alamat Lengkap
: ................................................................................................. ..................................................................................................
Jenis Pemeriksaan
: ................................................................................................. Cot Girek, ....................................... Ruangan Pengirim
Nip.
FORMULIR UMPAN BALIK Nama Pasien
: ...............................
Umur
: ............ Tahun.
Jenis Kelamin: L/P
Ruangan Yang Mengirim : ................................................................................................. .................................................................................................. Hasil Pemeriksaan
: ................................................................................................. Cot Girek, ....................................... Ruangan Penerima
Nip.
UPTD PUSKESMAS COT GIREK KECAMATAN COT GIREK Jln. Lhoksukon – Cot Girek, Batu XII Kode Pos 24383 Email : [email protected]. No Hp: 0823 6333 7828
FORMULIR RUJUKAN INTERNAL Nama Ruangan Pengirim
: .............................................................................................
Nama Ruangan ditiju
: ...........................................................................................
Nama Pasien
: ............................... Umur: ......... Tahun.
Jenis Kelamin: L/P
Alamat Lengkap
: ................................................................................................. ..................................................................................................
Jenis Pemeriksaan
: ................................................................................................. Cot Girek, ....................................... Ruangan Pengirim
Nip.
FORMULIR UMPAN BALIK Nama Pasien
: ...............................
Umur
: ............ Tahun.
Jenis Kelamin: L/P
Ruangan Yang Mengirim : ................................................................................................. .................................................................................................. Hasil Pemeriksaan
: ................................................................................................. Cot Girek, ....................................... Ruangan Penerima
Nip.
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