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  • Formulir Second Opinion

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    This document is a request form for a second medical opinion from Rumah Sakit As-Syifa hospital in Manna, Bengkulu Selatan, Indonesia. The form requests information such as the patient and requester's name, date of birth, address, and medical record number. It states that the requester understands the benefits of a second opinion and had their questions answered satisfactorily. It also notes that medical science is not exact and expert opinions can differ. The requester acknowledges financial responsibility for the costs of the second opinion. The form must be signed by the patient or guardian and a witness.

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    This document is a request form for a second medical opinion from Rumah Sakit As-Syifa hospital in Manna, Bengkulu Selatan, Indonesia. The form requests information such as the patient and requester's name, date of birth, address, and medical record number. It states that the requester understands the benefits of a second opinion and had their questions answered satisfactorily. It also notes that medical science is not exact and expert opinions can differ. The requester acknowledges financial responsibility for the costs of the second opinion. The form must be signed by the patient or guardian and a witness.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views1 page

    Formulir Second Opinion

    Uploaded by

    akreditasirshd
    This document is a request form for a second medical opinion from Rumah Sakit As-Syifa hospital in Manna, Bengkulu Selatan, Indonesia. The form requests information such as the patient and requester's name, date of birth, address, and medical record number. It states that the requester understands the benefits of a second opinion and had their questions answered satisfactorily. It also notes that medical science is not exact and expert opinions can differ. The requester acknowledges financial responsibility for the costs of the second opinion. The form must be signed by the patient or guardian and a witness.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    RUMAH SAKIT AS-SYIFA

    Jl. Gerak Alam RT. 13 Kelurahan Kota Medan


    Kecamatan Kota Manna Kabupaten Bengkulu Selatan
    Telp. (0739) 2188 Email : rs.assyifa.manna@gnail.com

    PER SE TU JUA N PER M IN TAA N PE ND A PAT LA IN ( SE C ON D OP IN IO N )

    Yang bertandatangan di bawah ini, saya :


    Nama : ………………………………………………………………
    Tgl lahir : ………………………………………………………………
    Alamat : ………………………………………………………………

    Dengan ini menyatakan permintaan untuk mendapat second opinion terhadap diri saya sendiri*/ suami*/
    istri*/ anak*/ ayah* / ibu*/ wali*, dengan
    Nama : ………………………………………………………………
    Tgl lahir : ………………………………………………………………
    Alamat : ………………………………………………………………
    No. MR : ………………………………………………………………

    Saya memahami perlunya dan manfaat second opinion tersebut sebagaimana telah dijelaskan kepada
    saya. Saya telah mendapat kesempatan untuk bertanya dan telah mendapat jawaban yang memuaskan.
    Saya juga menyadari bahwa oleh karena ilmu kedokteran bukanlah ilmu pasti dan selalu berkembang,
    maka perbedaan pendapat ahli adalah biasa terjadi dalam dunia kedokteran. Saya menyadari beban biaya
    second opinion menjadi tanggung jawab saya.

    Manna, ........................
    Saksi Pasien / Wali**

    (..............................) (............................)

    *) Coret yang tidak perlu


    **) Bila pasien tidak kompeten atau tidak mau menerima informasi, maka wali atau seseorang yang
    diberi hak untuk menyetujui tindakan terhadap pasien tersebut.

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