BPS “KASIH IBU”
Ds. CONDONG CATUR
Kab. SLEMAN
Telp.
0274xxxxxxx
Nomor : Yogyakarta,_________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
________________________________
________________________________
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