Surat Rujukan

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SURAT RUJUKAN

Bidan :……………………… …………. Kepada

Alamat / No. Telp :…………..……………………… Yth………………………….
………………………………
………………………………

Dengan ini saya kirimkan penderita :

Nama Pasien :……………………………… ………………………………………….

Umur :…………………………… …………………………………………….
Alamat :………… … ……………………………………………………………
Pekerjaan :…………………………………………………………………………..
Dengan DX / Keluhan :…… …………………………………………………………………….
……………………..…………………………………………………………………………….
…………………………………………………………………….…………………………..…
…………………………………………………………………………………………………...
………………….……………………………………………………………………………......
…………………………………………………………………………………………………...
Tx Sementara :…………………………………………………………………………..

Mohon penanganan lebih lanjut. Terima kasih

Mojokerto, ………………………………….

(………………………………………..)

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