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PT.

Askes (Persero)
Kantor Regional / Kantor Cabang : REGIONAL VII - SURABAYA / KEDIRI

Rujukan Puskesmas / Dokter Keluarga

SURAT RUJUKAN PESERTA

No. Rujukan : .............................................

Puskesmas/Dokter Keluarga : ...................................................... Kode : .........................


Kabupaten/Kota : ..................................................... Kode : ........................

Kepada Yth. TS dr. Poli : ................................................................................

Di RSU : ................................................................................

Mohon pemeriksaan dan penanganan lebih lanjut penderita :

Nama : ................................................... Umur : ......... Tahun ....................

No. Kartu BPJS : ..................................................... Status : Utama/ Tanggungan P (L/P)

Diagnosa : ....................................................

Telah diberikan :

Demikian atas bantuannya, diucapkan banyak terima kasih

Salam sejawat, ...................... 2014

dr.............................

SURAT RUJUKAN BALIK

Teman sejawat Yth.


Mohon kontrol selanjutnya penderita :

Nama : .........................................................................................................................................

Diagnosa : .........................................................................................................................................

Terapi : .........................................................................................................................................

Tindak lanjut yang dianjurkan

Pengobatan dengan obat-obatan : Perlu rawat inap

............................................................................. Konsultasi selesai

Kontrol kembali ke RS tanggal : ......................... ................................ tgl .......................................

Lain-lain : ............................................................

Dokter RS,
(..........................................................)