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PEMERINTAH KABUPATEN SERANG

DINAS KESEHATAN
UPT PUSKESMAS DTP PETIR
Jln. Raya Tunjung – Petir Km. 17 Kec. Petir Telp. (0254) 8487100
Email : pkm.petir@gmail.com

RUJUKAN SKTM PUSKESMAS PETIR
SURAT RUJUKAN
No. Rujukan : /PKM/PTR/ / 2017

Puskesmas/Dokter Keluarga : ..................................................................... Kode : .........................
Kabupaten/Kota : ..................................................................... Kode : .........................

Kepada Yth. TS Dr.Poli : ....................................................................
DIRSU : ....................................................................
Mohon Pemeriksaan dan penanganan lebih lanjut penderita :
Nama : ....................................................................
Umur : .................Tahun/Kelamin : L/P
Alamat : ………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………..
Diagnosa : ....................................................................
Telah diberikan : ....................................................................
Demikian atas bantuannya, diucapkan banyak terima kasih.
Salam Sejawat, ..........................................

(..................................................................)

SURAT RUJUKAN BALIK
Teman sejawat Yth.
Mohon kontrol selanjutnya penderita :
Nama : ........................................................................................................
Diagnosa : ........................................................................................................
Terapi : ........................................................................................................
Tindak Lanjut yang diajukan
Tindakan Pengobatan dengan Obat-obatan
......................................................................................................................................
………………………………………………………………………………………………………………………………..
Kontrol kembali ke RS tanggal :.............................................................
Lain-lain : ................................................................................................
Perlu Rawat Inap
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