7.10.3.Ep 2 Form Rujukan

PEMERINTAH KABUPATEN TANGGAMUS

DINAS KESEHATAN UPT PUSKESMAS MARGOYOSO  Jl. Kesehatan No. 1 Margoyoso Kec. Sumberejo Sumberejo – Tanggamus Tanggamus  No Telp/Hp. Telp/Hp. ( 0!1"#11$%0& '.Mal '.Mal ) *+mmargoyoso,gmal.com ) *+mmargoyoso,gmal.com Ko-e  Ko-e *os "%##!

SURAT SURAT RUJUKAN RUJU KAN Margoyoso,...../..................../2017  Nomor Lampiran Perihal Yh. !oker "aga #$! !i R%#

: : : Rujukan Pasien :............................................. :.............................................

!engan &orma , Mohon pemeriksaan 'an pengo(aan le(ih lanju erha'ap pen'eria,  Nama :................................................... "eni enis )el )elami amin :.... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .. #mur :.................................................... *lama :....................................................  Nomor +P"% :.................................................... *namnesa )eluhan : ................................................. ....................................................... ........................................................................................... .................................... ............................................................................................................................................................ ......... Pemeriksaan isik : ............................................................................................................................................................ ...................................................................................................................................................... ..................................................................................................................................................... !iagnosa semenara :   ................................................................................................. -erapi/(a yang elah 'i(erikan : .......................................................................................... .................................................................................................................................................

!emiki !emikian an sura sura rujuka rujukan n ini kami kami kirim, kirim, kami kami mohon mohon (alasa (alasan n aas aas sura sura rujuka rujukan n ini. ini. *as *as  perhaian +apak/(u kami uapkan erima kasih.

&orma )ami, !oker "aga Puskesmas Margoyoso

 .............................................   NP/NRP--. Lembar 1 : Untuk Ruma !ak"t ru#ukan Lemabar $ : Untuk %a&'ran PKM