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LEMBARAN KONSULTASI
Tanggal Tanggal
: ......................... ..................
Kepada Yth.
:
TS. dr. ............................................................ .......................................................................
Dengan hormat, Mohon konsul dan advis terapi / ambil alih / rawat bersama dengan Diagnosa Sementara : ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... Salam Sejawat,
dr. ............................... Tanggal Tanggal Yth. TS agian
!.
: ......................... .................. : dr. .......................... ............ : ......................... ..................