8/17/2019 Form Rujuk Balik

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PEMERINTAH KABUPATEN SUKABUMI

BLUD RSUD PALABUHANRATUJl. Jend. A. Yani No. 2 Telp. (0266) 420!" #a$ (0266) 420!2

Pala%&'ana& * S&+a%&,i

RUJUKAN BALIK 

 No.

Palabuhanratu, ......................

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Kepada Yth.

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Bersama ini kami sampaikan bahwa, pasien  Nama .....................................................................................................

Umur .....................................................................................................

Alamat .....................................................................................................

!tatus Pasien Umum " Jamkesmas " #akinda " A!K$! " Kontraktor 

Berobat di Poliklinik"U#% .....................................................................................................

%i rawat di Ruan&an .....................................................................................................

'an&&al Perawatan .....................................................................................................

%ia&nosa .....................................................................................................

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'indakan Pen&obatan (an& telah dilakukan ...................................................................................

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Kami Ru)uk kembali ke Rumah !akit " Puskesmas setempat untuk mendapatkan Perawatan "

Pen&obatan " tindakan selan)utn(a

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%emikian, atas ker)asama (an& baik kami u*apkan terimakasih.

!alam !e)awat,

%okter (an& merawat

%r......................................