Surat Rujukan Antar Poli

SURAT RUJUKAN ANTAR POLI

KEPADA POLI : UMUM/IGD DENGAN INI KAMI KIRIMKAN PASIEN NAMA : .....................................L/ .....................................L/P P UMUR : .....................................T .....................................Tahun ahun  ALAMAT : ..................................... ..................................... HASIL PEMERIKSAAN PEMERIKSAAN : ................................ ..................................... ..... ....................................... DIAGNOSA : .................................... .................................... KODE ICD : .................................... .................................... MOHON PENANGANAN DAN PERAWATAN LEBIH LANJUT PASIEN TERSEBUT DI ATAS  ATAS KERJA SAMANYA DIUCAPKAN DIUCAPKAN TERIMAKASIH PENGIRIM PETUGAS POLI GIGI

(.....................)  potong disini ..................................... ...................................... potong ......................................................... ....................................... ....................................... .............................. .......... UMPAN BALIK RUJUKAN PASIEN

NAMA : UMUR : HASIL PEMERIKSAAN : ................................................ ...................................................................... .......................................... ......................... ..... ........................................ .......................................................... ....................................... ..................................... ................ DEMIKIAN HASIL PEMERIKSAAN INI KAMI SAMPAIKAN  AGAR DAPAT DIPERGUNAKAN SEPERLUNYA

PETUGAS POLI/IGD

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