Kepada Yth : ……………………………………………………………………..

To ……………………………………………………………………..

Dengan ini kami kirimkan pasien untuk pemeriksaan / perawatan selanjutnya.

Here I refer a patient for further medical check up / treatment,

Nama Pasien : ……………………………………………………………… Jenis kelamin : ………………………………….

Name of patient Sexuality
Jenis Hewan / Umur : …………………………………………………………….. Berat Badan : ………………………………….
Animal Race / Age Body Weight
Nama Pemilik / pengantar: ……………..……………………………………………… No Telp / HP : …………………………………………………
Name of relatives Phone Number
Alamat : ……………………………………………………………………………………………………………………………………………..
Address ……………………………………………………………………………………………………………………………………………..

Pemeriksaan fisik : ……………………………………………………………………………………………………………………………………………..

Physical Examination …………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………….

Pemeriksaan Penunjang : ………………………………………………………………………………………………………………………………………………

Additional Examination ……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..

Diagnosa : ………………………………………………………………………………………………………………………………………………..
Diagnosis ………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………..

Terapi dan tindakan yang diberikan :……………………………………………………………………………………………………………………………..

Performed medication & procedure ………………………………………………………………………………………………………………………………
.……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………..
Alasan dirujuk / Reasons referenced
Tempat penuh/ Unavailable Room
Atas permintaan Klien atau keluarga/ Patient’s or families preferable
Fasilitas tidak tersedia/No Facility
Xray Posisi Fokus

Terima kasih atas kerjasamanya.

Thank you for your cooperation

Surabaya, …………………………………….
Salam Sejawat
Dokter yang merawat/Attending Physician