Tanggal : ...........................................

Kepada Yth. :

TS. dr. ............................................................

.......................................................................

Dengan hormat,

Mohon konsul dan advis terapi / ambil alih / rawat bersama dengan Diagnosa Sementara :

...................................................................................................................................................................................

...................................................................................................................................................................................

...................................................................................................................................................................................

...................................................................................................................................................................................

...................................................................................................................................................................................

Salam Sejawat,

dr. ...............................

Tanggal : ...........................................

Yth. TS : dr. ......................................

Bagian : ...........................................

1. Pada pemeriksaan pasien, didapat : .................................................................................................................

...................................................................................................................................................................................

...................................................................................................................................................................................

...................................................................................................................................................................................

2. Anjuran : ...........................................................................................................................................................

...................................................................................................................................................................................

...................................................................................................................................................................................

3. Terapi : ..............................................................................................................................................................

...................................................................................................................................................................................

...................................................................................................................................................................................

Salam Sejawat,

dr. ...............................

Nama Pasien :

Umur :

No. RM :

LEMBARAN KONSULTASI

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