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SURAT RUJUKAN SURAT RUJUKAN

Kepada Yth. Kepada Yth.


TS .................................................................... TS ....................................................................
Di ..................................................................... Di .....................................................................

Dengan hormat, Dengan hormat,


Mohon pemeriksaan dan pengobatan lebih lanjut terhadap pasien Mohon pemeriksaan dan pengobatan lebih lanjut terhadap pasien
Nama : ………………………..………………………………………………………. Nama : ………………………..……………………………………………………….
Tgl. Lahir : ………………………..………………………………………………………. Tgl. Lahir : ………………………..……………………………………………………….
Umur : ………………… tahun Jenis Kelamin :  Laki-laki  Perempuan Umur : ………………… tahun Jenis Kelamin :  Laki-laki  Perempuan
Alamat : ………………………..………………………………………………………. Alamat : ………………………..……………………………………………………….
………………………..………………………………………………………. ………………………..……………………………………………………….
No. Telp : ………………………..………………………………………………………. No. Telp : ………………………..……………………………………………………….

Dengan anamnesa : Dengan anamnesa :


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Diagnosa sementara : Diagnosa sementara :
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Terapi dan pengobatan yang telah diberikan : Terapi dan pengobatan yang telah diberikan :
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Demikian surat rujukan ini kami kirimkan dan kami mohon balasan atas rujukan ini. Atas Demikian surat rujukan ini kami kirimkan dan kami mohon balasan atas rujukan ini. Atas
perhatian dan kerja sama yang diberikan, kami ucapkan terima kasih. perhatian dan kerja sama yang diberikan, kami ucapkan terima kasih.
Surabaya, ………………………………... Surabaya, ………………………………...
Hormat kami, Hormat kami,

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