Form Rujukan Edukasi Berkelanjutan [PDF]

RUMAH SAKIT PUPUK KALTIM PRIMA SANGATTA Jl. Yos Sudarso 1, No.1, Kutai Timur,Kalimantan Timur Telp. (0549) 24555 Fax. (0

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RUMAH SAKIT PUPUK KALTIM PRIMA SANGATTA Jl. Yos Sudarso 1, No.1, Kutai Timur,Kalimantan Timur Telp. (0549) 24555 Fax. (0549) 24524 e-mail : [email protected]

FORM RUJUKAN EDUKASI BERKELANJUTAN No : .................................. Kepada Yth, Mohon di tindaklanjuti, Nama

:

Alamat

:

No. Handphone

:

Selama dirawat di RS Pupuk kaltim Prima Sangatta telah mendapat edukasi : 1.

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

2.

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

3.

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

Untuk promosi kesehatan berkelanjutan mohon untuk diberikan edukasi lanjutan : 1.

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

2.

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

3.

......................................................................................................................................... Demikian rujukan ini kami sampaikan, atas perhatian dan kerjasamanya kami

ucapkan terima kasih. Sangatta ,....................................... Petugas kesehatan

Keterangan : Lembar 1 Lembar 2

: untuk pasien : untuk arsip

Pasien/keluarga pasien