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PEMERINTAH KABUPATEN JENEPONTO

DINAS KESEHATAN DAERAH

PUSKESMAS TAROWANG
Desa Tarowang, Kec. Tarowang, Kab. Jeneponto

SURAT RUJUKAN
Nomor : ……………………………………..

Kepada
Yth. TS. …………………………
…………………………………..
Di –
RSUD …………………………………..

Mohon pemeriksaan, pengobatan, dan perawatan lanjut terhadap pasien :

Nama : ………………………………………………………………………………………………………………………
Umur : ………………………………………………………………………………………………………………………
Jenis kelamin : ………………………………………………………………………………………………………………………
Pekerjaan : ………………………………………………………………………………………………………………………
Alamat : ………………………………………………………………………………………………………………………

Diagnosis sementara : - ………………………………………………………………………………………………………………

- ………………………………………………………………………………………………………………
- ………………………………………………………………………………………………………………

Penatalaksanaan awal : - ………………………………………………………………………………………………………………

- ………………………………………………………………………………………………………………
- ………………………………………………………………………………………………………………
- ………………………………………………………………………………………………………………
- ………………………………………………………………………………………………………………
- ………………………………………………………………………………………………………………

Atas bantuan dan perhatian tersebut diucapkan terima kasih.

Tarowang, ………………………………………2018
Puskesmas Tarowang
Dokter yang mengirim,

dr. Muhammad Syahrir

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