7/25/2019 Surat Rujuka BPJS

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SURAT RUJUKAN PESERTA

:No. Rujukan

KAB. BOJONEGORO 0202::Kabupaten/Kota

MARGOMULYOPuskesmas/Dokter Keluarga 13041502Kode :Kode :

Kepada Yth. TS dr. Poli

Di RSU

Mohon pemeriksaan dan penanganan lebih lanjut penderita :

No. Kartu BPJS

Nama

Telah diberikan

Diagnosa

Demikian atas bantuannya, diucapkan banyak terima kasih

Salam sejawat,

Umur :

Status :

Tahun

( L / P )Utama/ Tanggungan

:

:

:

:

:

:

Rujukan Puskesmas / Dokter Keluarga

SURAT RUJUKAN BALIK

Teman sejawat Yth.Mohon kontrol selanjutnya penderita :

Nama :

Diagnosa :

Terapi :

Tindak lanjut yang dianjurkan

Pengobatan dengan obat-obatan :

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Kontrol kembali ke RS tanggal : .........................

Lain-lain : ............................................................

Perlu rawat inap

Konsultasi selesai

................................ tgl .......................................

Dokter RS,

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BOJONEGORO

Divisi Regional REGIONAL VII - SURABAYA

Kantor Cabang

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