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  • Uptd Puskesmas Pulokulon Ii: Dinas Kesehatan

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    This document is a consent or refusal form for medical treatment from the Puskesmas Pulokulon II health center in Groboagan Regency. It records the name, gender, age, and address of the patient and the person providing consent. The form states whether the person consents or does not consent to a specified medical procedure, along with the risks of that procedure. It confirms that the risks and potential outcomes of the procedure and associated illness were explained to the person providing consent. Spaces are provided for signatures of the treating medical professional, the consenting person, and two witnesses.

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    Original Title

    Informed Consent

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    This document is a consent or refusal form for medical treatment from the Puskesmas Pulokulon II health center in Groboagan Regency. It records the name, gender, age, and address of the patient and the person providing consent. The form states whether the person consents or does not consent to a specified medical procedure, along with the risks of that procedure. It confirms that the risks and potential outcomes of the procedure and associated illness were explained to the person providing consent. Spaces are provided for signatures of the treating medical professional, the consenting person, and two witnesses.

    Copyright:

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

    Uptd Puskesmas Pulokulon Ii: Dinas Kesehatan

    Uploaded by

    kharismasetyaharnani
    This document is a consent or refusal form for medical treatment from the Puskesmas Pulokulon II health center in Groboagan Regency. It records the name, gender, age, and address of the patient and the person providing consent. The form states whether the person consents or does not consent to a specified medical procedure, along with the risks of that procedure. It confirms that the risks and potential outcomes of the procedure and associated illness were explained to the person providing consent. Spaces are provided for signatures of the treating medical professional, the consenting person, and two witnesses.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    PEMERITAH KABUPATEN GROBOGAN

    DINAS KESEHATAN
    UPTD PUSKESMAS PULOKULON II
    Jl. Raya Danyang – Kuwu KM. 12 SembungharjoKec. Pulokulon
    KodePos 58181 Telp: (0292) 7621057
    Email: puskesmaspulokulon2@gmail.com

    SURAT PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS

    Saya yang bertanda tangan di bawah ini :


    Nama :
    Jenis Kelamin :
    Umur :
    Alamat :

    Menyatakan dengan sesungguhnya dari saya sendiri / orang tua / suami / istri / anak /
    wali* dari :
    Nama :
    Jenis Kelamin :
    Umur :
    Alamat :

    Dengan ini menyatakan SETUJU / TIDAK SETUJU* untuk dilakukan tindakan medis
    berupa ..........................................................................................................................
    dengan resiko tindakan berupa....................................................................................

    Dari penjelasan yang telah diberikan, saya telah mengerti dengan segala hal yang
    berhubungan dengan penyakit tersebut, serta tindakan medis yang akan dilakukan dan
    kemungkinan pasca tindakan yang dapat terjadi sesuai penjelasan yang diberikan.

    Sembungharjo, ....................................
    Pelaksana Tindakan Yang membuat Pernyataan

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

    Saksi I Saksi II

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

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