DINAS KESEHATAN KABUPATEN MIMIKA

PUSAT KESEHATAN MASYARAKAT TIMIKA

Jl. Trikora NO. 23 Telepon (0901) -322514 Kode Pos 99910
TIMIKA - PAPUA

SURAT RUJUKAN PASEN

Nomor : 812/ / /PKM-TMK/ 201
Kepada Yth.
...........................................
Di.......................................

Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita :

- Nama :..........................................................................................
- Uumur :..........................................................................................
- Jenis kelamin :...........................................................................................
- Nama kepala Keluarga:..........................................................................................
- Pekerjaan :...........................................................................................
- Alamat :...........................................................................................
-
Anamnese :...........................................................................................
:........................................... ................................................
:...........................................................................................
:...........................................................................................
Diagnosa sementara :............................................................................................
:............................................................................................
Therapy :............................................................................................
Rujuk Ke :............................................................................................

Demikian atas bantuannya dan kerja sama yg baik disampaikan terima kasih serta mohon
Informasi lebih lanjut terhadap penderita tersebut.
Timika,....................................
Dokter/Petugas

Drg. Marliana Tarukponno

Nip.1975 1117 20006 05 2 001
Catatan :Mohon pasen dirujuk kembali

x....................................................................................................................................................
SURAT RUJUKAN BALIK

TS YTH :
Mohon kontrol lebih lanjut penderita :
Nama :.........................................................................................
Umur :.........................................................................................
Diagnosa :.........................................................................................
Tindak Lanjut Yang diberikan
1.Pengobatan yg diberikan :.........................................................................................................
2.Kontrol kembali di RS tanggal :.........................................................................................................
3.Keterangan :.........................................................................................................

Timika,............................................
Dokter/petugas

........................................................
NIP.
 Divisi Regional REGIONAL XII JAYAPURA

Kantor Cabang TIMIKA

RUJUKAN PPK : PUSKESMAS TIMIKA