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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