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KLINIK CAHAYA Jl. Diponegoro No. 126 Telepon (0332) 5552533 / 081330830001 Email : www.klinikCahaya.gmail.com / Kode pos 68213



BONDOWOSO SURAT RUJUKAN NO TANGGAL JAM JENIS PASIEN



: : : : 1. Umum 2. BPJS , NO : ........................................................... 3. ............................................................................. Kepada Yth. ...................................... di ...................................



Mohon bantuan perawatan dan pengobatan selanjutnya pendereta : Nama



: ...................................................... L/P Umur : ...........................................



Alamat



: ....................................................................................................................



KU



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Pemeriksaan Fisik



: ....................................................................................................................



Pemeriksaan Penunjang



: .................................................................................................................... ....................................................................................................................



Doagnosis



: ....................................................................................................................



Pengobatan yang telah diberikan



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Alasan dirujuk



: .................................................................................................................... ..................................................................................................................... Pengirim (



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