Rujukan Interna

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PEMERINTAH KABUPATEN KARANGASEM

DINAS KESEHATAN
PUSKESMAS RENDANG
RUJUKAN INTERNAL
Kepada
No. / / /20 Yth : Petugas Unit
…………………
…………………
Menghadapkan pasien :

Nama :………………………………………………………………………....
Umur :………………………………………………………………………….
Jenis Kelamin : L/P
Alamat :………………………………………………………………………….
Diagnosa :………………………………………………………………………….
………………………………………………………………………….
Hasil Pemeriksaan :…………………………………………………………………………..
………………………………………………………………………….
………………………………………………………………………….
Mohon konsultasi/penanganan lebih lanjut. Terima kasih.

Rendang,
Petugas yang memeriksa

(………………………..)

PEMERINTAH KABUPATEN KARANGASEM

DINAS KESEHATAN
PUSKESMAS RENDANG
RUJUKAN INTERNAL
Kepada
No. / /20 Yth : Petugas Unit
…………………
…………………
Menghadapkan pasien :

Rendang,
Petugas yang memeriksa

(………………………..)

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