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DINAS KESEHATAN KABUPATEN KARAWANG

PUSKESMAS: RAWAMERTA

TgL..................................

SURAT RUJUKAN No : / PKM / /2016

KepadaDengan hormat, Yth,

TS.................................

RS : ..................................Mohon Kons!/pemer"#sa/Pengo$atan!e$"h !an%t terhadap Pender"ta :

Nama Pender"ta : .................................................................................................

&mr : .................................hr/$!an/tahn...........'/P(!amat : Kp ..................................................................... Desa: ....................................................................................................................................................................................................

Ke)amatan : .......................................................................................................................

(namnese : .............................................................................................................................D"agnosa Sementa

: .............................................................................................................................*$at Yang Sdah d"$er"#an

: ...........................................................................................................................Ter"ma #as"h : ............................................................................................................................

+aa$an R%#an

Kons! Se!esa"/Per! Kontro! Kem$a!"Kons! Sesa"/Per! #ontro! Kem$a!"Per! Kons! #e (h!" 'a"n -Se$t#an

: ............................................................................................................................Peer! T"nda#an Med"s 'a"n -Se$t#an

: ............................................................................................................................Per! d"raat dengan nd"#as" -Se$t#an :!..................................................................................................................................

D"agnose : ............................................................................................................................

Terap" Yang D"$er"#an : ............................................................................................................................

(n%ranTangga! Dan atatan : ............................................................................................................................

.............................................................................................................................

&nt# d"#em$a!"#an Pada Do#ter Peng"r"m Sete!ah Se!esa"er!# 1 !an &nt# Pena#"t Keras

Sa!am se%aat

dr.Stard"NRPTT:345.52.1.11.1.

Sa!am se%aat

- ..................................

......

7/25/2019 RUJUKAN UMUM.docx

2/3

DINAS KESEHATAN KABUPATEN KARAWANG

PUSKESMAS: RAWAMERTA

TgL..................................

SURAT RUJUKAN

No: /PKM/ / 2016

KepadaDengan hormat, Yth,

Ts ...........................

RS : ................................Mohon Kons!/pemer"#sa/Pengo$atan !e$"h !an%t terhadap Pender"ta :

Nama Pender"ta : .................................................................................................&mr : .................................hr/$!an/tahn............'/P(!amat : Kp ..................................................................... Desa: .......................................................

............................................................................................................................................. Ke)amatan : .......................................................................................................................

(namnese : .............................................................................................................................D"agnosa Sementa

: .............................................................................................................................*$at Yang Sdah d"$er"#an

: ...........................................................................................................................Ter"ma #as"h : ............................................................................................................................

+aa$an R%#an

Kons! Se!esa"/Per! Kontro! Kem$a!"Kons! Sesa"/Per! #ontro! Kem$a!"Per! Kons! #e (h!" 'a"n -Se$t#an

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

Peer! T"nda#an Med"s 'a"n-Se$t#an : .............................................................................................................................Per! d"raat dengan nd"#as"-Se$t#an : .............................................................................................................................

Sa!am se%aat

dr.7neng S#maant"NP:

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D"agnose : ............................................................................................................................

Terap" Yang D"$er"#an : .............................................................................................................................

(n%ranTangga! Dan atatan : ............................................................................................................................

.............................................................................................................................

&nt# d"#em$a!"#an Pada Do#ter Peng"r"m Sete!ah Se!esa"er!# 1 !an &nt# Pena#"t Keras

Sa!am se%aat

- ..................................

......