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SURAT RUJUKAN Yth : ...................................................................................................................................... Di Puskesmas : ...................................................................................................................................... Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita Nama Pasien : ...................................................................................................................................... Jenis kelamin : ...................................................................................................................................... Umur : ...................................................................................................................................... Alamat Rumah : ...................................................................................................................................... Anamnesa Keluhan : .................................................................................................................................................................... ................................................................................................................................................................ Therapi Obat .................................................................................................................................................................... ................................................................................................................................................................ Demikian surat rujukan ini kami kirim, kami mohon tindak lanjutnya Girimukti,....................20..... Pemeriksa
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SURAT RUJUKAN Yth : ...................................................................................................................................... Di Puskesmas : ...................................................................................................................................... Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita Nama Pasien : ...................................................................................................................................... Jenis kelamin : ...................................................................................................................................... Umur : ...................................................................................................................................... Alamat Rumah : ...................................................................................................................................... Anamnesa Keluhan : .................................................................................................................................................................... ................................................................................................................................................................ Therapi Obat .................................................................................................................................................................... ................................................................................................................................................................ Demikian surat rujukan ini kami kirim, kami mohon tindak lanjutnya Girimukti,....................20..... Pemeriksa
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