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RUMAH SAKIT MITRA MEDIKA NAROM Jl. Jatiwangi-Cikedokan/ Sebelah Selatan Kawasan MM 2100 Kp. Kamurang RT 01 RW 1 Desa Cikedokan Cikarang Barat – Kab. Bekasi Telp. 021- 89983741 Fax: 021-89983575
FORMULIR RUJUKAN HIV / AIDS Nama Instansi Pengirim ................................................................................................................................................................. Nama Instansi Penerima................................................................................................................................................................. Nama Pasien.......................................................................................Umur..................Tahun, Jenis kelamin: L/P Alamat Lengkap .............................................................................................................................................................................. ............................................................................................................................................................................. No. Rekam Medis :
No. MR : -
Tanggal konfirmasi tes HIV + : .....................................................Tempat : ................................................................................. Keadaan pada saat rujukan :
Stadium klinis WHO Berat Badan Status fungsional Rejimen yang diberikan
IO yang terjadi terapi Profilaksis IO Status TB
: : : :
1/ 2/ 3/ 4 .............kg K/ Amb/ Bar ......................................................................................................................................... ......................................................................................................................................... : ......................................................................................................................................... : ......................................................................................................................................... : 1. Bukan TB; 2. Suspek TB; 3. TB dalam pengobatan
Bersama ini kami lampirkan pula salinan ikhtisar perawatan HIV dan ART
Bekasi, tgl
(Dr
)
RUMAH SAKIT MITRA MEDIKA NAROM Jl. Jatiwangi-Cikedokan/ Sebelah Selatan Kawasan MM 2100 Kp. Kamurang RT 01 RW 1 Desa Cikedokan Cikarang Barat – Kab. Bekasi Telp. 021- 89983741 Fax: 021-89983575