7/25/2019 Surat Rujukan JAMKESDA

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PEMERINTAH KABUPATEN PENAJAM PASER UTARA

DINAS KESEHATAN

UPT PUSKESMAS PENAJAMAlamat :JL. Propinsi. Penajam KM. . TELP. !"#$%& '%""'() Ko*e Pos '($ Kal+Tim

Dari P,s-esmas : Penajam Keamatan : Penajam

Kepa*a RS : ............................... Poli-lini- : ...............................

TS /t01

Den2an ini -ami mo0on ,nt,- *ila-,-an pemeri-saan 3 pen2o4atan lanj,t ter0a*ap pen*erita :

Nama : ............................................ Um,r : ............................................

NIK : ............................................ J. Kelamin : ............................................

Alamat : ............................................ Stat,s : KK 3 S 3 I 3 A 11111113 DLL

Hasil Pemeri-saan Sementara :

Anamnesa : .............................................................................................................................

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Pemeri-saan 5isi- : .............................................................................................................................

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Dia2nosa : .............................................................................................................................

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Penatala-sanaan : .............................................................................................................................

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Demi-ian R,j,-an ini *isampai-an atas 4ant,an TS1 *i,ap-an terima -asi0.

RUJUKAN BALIK

/an2 Ter0ormat TS :

Bersama ini -ami sampai-an :

Nama : .............................................................................................................................

Dia2nosa : .............................................................................................................................

Terapi : .............................................................................................................................

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Tan22al1 .....3........................%".....

Do-ter P,s-esmas

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NIP ........................................

Salam Seja6at1

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N7 :

K7DE PKM SURAT RUJUKAN PESERTA JPK - PPU