Divisi Regional REGIONAL VI - SEMARAN

Kantor Cabang PURWOKERO

Rujukan Puskesmas / Dokter

Keluarga SURAT RUJUKAN

PESERTA

No! Ru ju$an %
Pus$es&as'Do$ter K eluarga % Ko(e %
Kabu)aten'Kota % Ko(e %

Ke)a(a *t+! S (r! Poli %

Di RSU %
Mo+on )e&eri$saan (an )enanganan lebi+ lanjut )en(erita %
Na&a % U&ur % a+un ,L ' P
No! K artu B P/S % Status %
Uta&a'anggungan Diagnosa %
 ela+ (iberi$an %
De&i$ian atas bantuann0a1 (iu2a)$an ban0a$ teri&a $asi+
Sala& Seja3at1 !!!!!!!!!!!!!!!!!!!

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SURAT RUJUK BALIK 

 e&an seja3at *t+!

Mo+on $ontrol selanjutn0a )en(erita %

Na&a %
Diagnosa %
 era)i %

 in(a$ lanjut 0ang (ianjur$an %

Pengobatan ( engan o bat-obatan Perlu R a3at I na)
%

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Kontrol $e&bali $e RS tanggal % !!!!!!!!!!!!!!!!!!!!!!!!!!! Konsultasi selesai

Lain-lain % !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!1 tgl !!!!!!!!!!!!!

Do$ter RS1
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