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  • Uptd Puskesmas Teluk Lubuk: Formulir Persetujuan Tindakan

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    nensy121
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    This document is a consent form from the Teluk Lubuk Public Health Center in Muara Enim Regency, Indonesia. It requests information from the patient and guardian, including their names, ages, addresses and medical procedure. It also specifies whether medical costs will be covered by the patient or by Indonesia's public health insurance program. The form states that the guardian understands the risks explained by the doctor and provides consent for the specified medical treatment. It is dated and requires signatures from the medical provider and patient/guardian.

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    INFORM CONSENT

    Original Title

    Informent Consent

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    This document is a consent form from the Teluk Lubuk Public Health Center in Muara Enim Regency, Indonesia. It requests information from the patient and guardian, including their names, ages, addresses and medical procedure. It also specifies whether medical costs will be covered by the patient or by Indonesia's public health insurance program. The form states that the guardian understands the risks explained by the doctor and provides consent for the specified medical treatment. It is dated and requires signatures from the medical provider and patient/guardian.

    Copyright:

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

    Uptd Puskesmas Teluk Lubuk: Formulir Persetujuan Tindakan

    Uploaded by

    nensy121
    This document is a consent form from the Teluk Lubuk Public Health Center in Muara Enim Regency, Indonesia. It requests information from the patient and guardian, including their names, ages, addresses and medical procedure. It also specifies whether medical costs will be covered by the patient or by Indonesia's public health insurance program. The form states that the guardian understands the risks explained by the doctor and provides consent for the specified medical treatment. It is dated and requires signatures from the medical provider and patient/guardian.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    PEMERINTAH KABUPATEN MUARA ENIM

    DINAS KESEHATAN
    UPTD PUSKESMAS TELUK LUBUK
    Jalan Raya Pendopo Desa Teluk Lubuk Kec.Belimbing, Kab. Muara Enim 31353

    FORMULIR PERSETUJUAN TINDAKAN


    Yang bertanda tangan di bawah ini :
    Nama :
    Umur :
    Alamat :

    Adalah bertindak sebagai diri saya/*orang tua/*suami/*istri/*anak/*wali dari penderita :

    Nama :
    Umur :
    Alamat :
    Dengan ini menyatakan telah memberikan persetujuan untuk dilakukan tindakan medis
    …………………………………/ rawat inap. Dengan biaya perawatan :
    *Atas tanggungan sendiri ( )
    *BPJS ( )

    Pernyataan ini saya buat dengan penuh kesadaran dan saya mengerti dengan semua penjelasan
    yang diberikan dokter / perawat. Demikian pernyataan ini saya buat, agar dapat digunakan
    sebagaimana mestinya.

    Teluk Lubuk, 2018


    Pukul : WIB

    Yang memberikan penjelasan


    Dokter / Perawat / Bidan Yang membuat pernyataan,

    (……………………………..) (……………………………….)

    Catatan : *coret yang tidak perlu

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