Contoh surat rujukan

 BPS “AS-SYIFA”

Ds. Mekar Sari Kab. Semarang

Telp. 024xxxxxxx

Nomor          :                                                                         Semarang,_________20___

Hal                : Rujukan Medik                                       Kepada

  Yth. __________________________

______________________________

______________________________

Di _________________

Bersama ini kami kirimkan penderita:

Nama                                      : ______________________________________________________

Umur                                      : ______________________________________________________

Alamat                                    : ______________________________________________________

Diagnosa                                : ______________________________________________________

                                                  ______________________________________________________

Pengobatan Sementara          : ______________________________________________________

                                                  ______________________________________________________

                                                  ______________________________________________________

Demikianlah atas kerjasamanya yang baik kami ucapkan terimakasih.

Keadaan waktu dirujuk :                                                               Semarang, ___________ 20 ___

________________________________                                                             Yang merujuk

________________________________

________________________________                                                        Diah Widyatun, S.SiT