surat rujuka

Contoh surat rujukan

BIDAN ASIH DWI ASTUTI

Jl. Lembah Merpati., Km XIII, Tanjungpinang Timur
HP.081 ..........

Nomor :                                                                            Tanjungpinang,_________20___

Hal                  : Rujukan Medik                                             Kepada

  Yth. __________________________

______________________________

______________________________

Di _________________

Bersama ini kami kirimkan penderita:

Nama                                       : ______________________________________________________

Umur                                       : ______________________________________________________

Alamat                                    : ______________________________________________________

Diagnosa                                 : ______________________________________________________

                                                  ______________________________________________________

Pengobatan Sementara            : ______________________________________________________

                                                  ______________________________________________________

                                                  ______________________________________________________

Demikianlah atas kerjasamanya yang baik kami ucapkan terimakasih.

Keadaan waktu dirujuk :                                              Tanjungpinang, ___________ 20 ___

________________________________                                                                               Yang merujuk

________________________________

________________________________                                Asih Dwi Astuti., SST., M.Kes