Contoh surat rujukan





 BPS “AS-SYIFA”
Ds. Mekar Sari Kab. Semarang
Telp. 024xxxxxxx



Nomor          :                                                                         Semarang,_________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 :                                                               Semarang, ___________ 20 ___
________________________________                                                             Yang merujuk
________________________________
________________________________                                                        Diah Widyatun, S.SiT

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