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RUJUKAN BALIK

Kepada Yth Teman Sejawat ..................................................................... Di tempat

Palembang, ............................................ (Tempat/ Place) (Tanggal/ Date) Jam/Time :

Dengan Hormat, Kami iriman embali pa!ien !a"dara,  #ama : ..................................... Tanggal Tanggal $ahir : ..................................... $/P Diagno!a : ............................................................. Pemeri!aan %ang telah tel ah dila"an dila "an : ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. .................................................................................................................................................................................................. Pengobatan & tindaan %ang telah diberian .................................................................................................................................................................................................. .................................................................................................................................................................................................. .................................................................................................................................................................................................. .................................................................................................................................................................................................. Kondi!i Saat p"lang :

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Cacat

Pakai alat bantu Dan lain-lain Kontrol lanj"tan,.............................................................................................................................................................. lanj"tan,.............................................................................................................................................................. 'enana Tindaan/ Pengobatan !elanj"tn%a........................................................................................................................... Keterangan lainn%a/ !aran, .................................................................................................................................................................................................. .................................................................................................................................................................................................. .................................................................................................................................................................................................. Demiian ami !ampaian, ata! erja!ama %ang bai ami meng"apan terima a!ih. Hormat ami , Doter Penangg"ng Jawab Pa!ien

................................................................ (Tanda Tangan & #ama $engap Doter)

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