8/18/2019 Surat Rotgen

1/1

DRG. JAN TERRIE L. ASSAU

SIP. 503.4/00018/KESRA-BPPT/2014

APOTIK BARIGAS, JLN. PATIH RUMBIH KUALA KAPUAS

KAB. KAPUAS, KALIMANTAN TENGAH

N0. TELP.

SURAT ROTGEN No. Surat : / / /

Kepada

Yth. : .............................................

Di : .............................................

Dengan Hormat,Melalui surat ini, kami mohon dilakukan Rotgen terhadap pasien ; Nama : .......................................................................................

Jenis Kelamin : .......................................................................................

mur : .......................................................................................

 No. !elepon : ......................................................................................."lamat Rumah : .......................................................................................

"namnesa : .......................................................................................

Diagnosa : .......................................................................................!u#uan Rotgen : .......................................................................................

Jenis Rotgen : .......................................................................................

$esan : .......................................................................................

% & ' ( ) * + + * ) ( ' & %

% & ' ( ) * + + * ) ( ' & %

 

Demikian surat rotgen ini kami sampaikan, "tas perhatian -apak/u kami u0apkanterima kasih.

........................, ....................  Hormat Kami,

1...............................2

 No. S$:..................