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DINAS KESEHATAN KABUPATEN CIANJUR DINAS KESEHATAN KABUPATEN CIANJUR DINAS KESEHATAN KABUPATEN CIANJUR

PUSKESMAS CIBAREGBEG PUSKESMAS CIBAREGBEG PUSKESMAS CIBAREGBEG


KECAMATAN CIBEBER KECAMATAN CIBEBER KECAMATAN CIBEBER
Kp. Nanggeleng Rt.007 / Rw.002 Desa Kp. Nanggeleng Rt.007 / Rw.002 Desa Kp. Nanggeleng Rt.007 / Rw.002 Desa
Cibaregbeg Kec.Cibeber Kab.Cianjur Cibaregbeg Kec.Cibeber Kab.Cianjur Cibaregbeg Kec.Cibeber Kab.Cianjur
Email: cibaregbeg.pkm@gmail.com Email: cibaregbeg.pkm@gmail.com Email: cibaregbeg.pkm@gmail.com

FORMULIR RUJUKAN INTERNAL FORMULIR RUJUKAN INTERNAL FORMULIR RUJUKAN INTERNAL


Ruangan pengirim : ...................................................... Ruangan Pengirim : ........................................................... Ruangan pengirim : ......................................................
Ruangan yang dituju : ...................................................... Ruangan yang dituju : ........................................................... Ruangan yang dituju : ......................................................
Nama Pasien : ...................................................... Nama Pasien : ........................................................... Nama Pasien : ......................................................
Umur : ...................................................... Umur : ........................................................... Umur : ......................................................
Jenis kelamin :L/P Jenis kelamin :L/P Jenis kelamin :L/P
Alamat : ...................................................... Alamat : ........................................................... Alamat : ......................................................
Jenis Pemeriksaan :...................................................... Jenis Pemeriksaan : ........................................................... Jenis Pemeriksaan : ......................................................

Cibaregbeg, ...2017 Cibaregbeg, ...2017 Cibaregbeg, ...2017

Petugas Pengirim Petugas Pengirim Petugas Pengirim

FORMULIR UMPAN BALIK FORMULIR UMPAN BALIK FORMULIR UMPAN BALIK


Nama Pasien :....................................................... Nama Pasien :............................................................ Nama Pasien :.......................................................
Umur : ...................................................... Umur : ........................................................... Umur : ......................................................
Jenis kelamin :L/P Jenis kelamin :L/P Jenis kelamin :L/P
Ruangan Pengirim : ...................................................... Ruangan Pengirim : ........................................................... Ruangan Pengirim : ......................................................
Hasil Pemeriksaan : Hasil Pemeriksaan : Hasil Pemeriksaan :
............................................................................................ ................................................................................................. ............................................................................................
............................................................................................ ................................................................................................. ............................................................................................

Cibaregbeg, ...2017 Cibaregbeg, ...2017 Cibaregbeg, ...2017


Petugas penerima Petugas penerima Petugas penerima