7101D BUKTI UMPAN BALIK RUJUKAN

 

 

BUKTI UMPAN BALIK RUJUKAN

 

                                                                                            Wonosobo,                          2013

Keterangan ( diisi oleh konsulen atau dokter yang menerima rujukan )

Nama penderita          :...........................................................................

Umur                           :...........................................................................

Alamat                        :...........................................................................

Pekerjaan                    :...........................................................................

Diagnosis                    :...........................................................................

Therapi                       :...........................................................................

                                    ............................................................................

                                    ............................................................................

                                                                                                Dokter yang menerima rujukan

 

                                                                                                       (........................................)

 

 

1.     Perlu kontrol kembali       :..........................................

2.     Perlu konsultasi ahli lain  :..........................................

3.     Konsultasi selesai             :..........................................

 

Lembar ini dikembalikan kepada pengirim setiap kali selesai konsul tasi