DIREKTORAT KESEHATAN ANGKATAN DARATRSPAD GATOT SOEBROTO

RUJUKAN PASIEN

Kepada Yth : ......................................................

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Kami mengirimkan pasien untuk perawatan selanjutnya, dengan alasan :

Tempat tidur penuh

Sesuai permintaan pasien / keluarga

Fasilitas Tidak Tersedia

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Dokter yang dituju : .....................................

Nama Pasien : ....................................... Jenis kelamin : .....................................

Tanggal Lahir : ....................................... No. RM : .....................................

Alamat : ............................................................................................................

Nama Pengantar / Keluarga Terdekat : ........................................................................

No. Telepon / HP : ………………………………………......................................................

Penanggung Jawab Biaya : ……………………………………………………..

Keluhan Utama : ..................................................................................................

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Pemeriksaan Fisik : ..................................................................................................

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Pemeriksaan Penunjang : ..................................................................................................

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Diagnosis : ..................................................................................................

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Terapi / Tindakan : ..................................................................................................

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Terima kasih atas kerjasamanya.

Jakarta, ....................................

Dokter yang merawat

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Tanda tangan dan nama jelas

RM-025/RI