Formulir Second Opini

Formulir Second Opinion Kepada Yth Ts Prof,DR,Dr Di Tempat

:

Hal : Pasien Rawat Inap /Rawat Jalan Salam Sejawat Mengenai pasien : …....................................................................yang kami rawat di …......................... RS Awal Bros Makassar Dari Tgl

: ….................................................. s/d …............................................................

Dapat kami sampaikan bahwa :......................................................................................................... Diagnosis

:...............................................................................................

Therapi yang diberikan

:...............................................................................................

Hasil penunjang Medis

:..............................................................................................

Pemeriksaan fisik

:...............................................................................................

Obat yang diberikan

:...............................................................................................

Rencana

:...................................................................................................

Terima kasih atas kerja samanya

Yang meminta

(….........................................) Nama jelas & tanda tangan

Salam Sejawat

(…............................................) Nama jelas & tanda tangan