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7/25/2019 Surat Rujukan JAMKESDA
1/1
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 : .............................................................................................................................
.............................................................................................................................
Pemeri-saan 5isi- : .............................................................................................................................
.............................................................................................................................
Dia2nosa : .............................................................................................................................
.............................................................................................................................
Penatala-sanaan : .............................................................................................................................
.............................................................................................................................
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 : .............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Tan22al1 .....3........................%".....
Do-ter P,s-esmas
!..............................................&
NIP ........................................
Salam Seja6at1
.....................................
N7 :
K7DE PKM SURAT RUJUKAN PESERTA JPK - PPU