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  • Tidaksetujuuntukdilakukantindakanmedis ..: Jl. Banyumas Km. 7 Telp. (0286) 324306kodepos56361

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    Ana sananta
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    This document is a consent form from the Selomerto 1 Community Health Center in Wonosobo Regency, Indonesia. It states that the signee consents to or does not consent to a medical procedure for themselves or a family member. The form captures the name, age, address and health ID of the patient, and confirms that the medical staff have explained the purpose, nature and risks of the procedure, and that the signee understands fully. It requires the signature of both the medical staff and the signee to validate the consent or non-consent.

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    This document is a consent form from the Selomerto 1 Community Health Center in Wonosobo Regency, Indonesia. It states that the signee consents to or does not consent to a medical procedure for themselves or a family member. The form captures the name, age, address and health ID of the patient, and confirms that the medical staff have explained the purpose, nature and risks of the procedure, and that the signee understands fully. It requires the signature of both the medical staff and the signee to validate the consent or non-consent.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    4 views2 pages

    Tidaksetujuuntukdilakukantindakanmedis ..: Jl. Banyumas Km. 7 Telp. (0286) 324306kodepos56361

    Uploaded by

    Ana sananta
    This document is a consent form from the Selomerto 1 Community Health Center in Wonosobo Regency, Indonesia. It states that the signee consents to or does not consent to a medical procedure for themselves or a family member. The form captures the name, age, address and health ID of the patient, and confirms that the medical staff have explained the purpose, nature and risks of the procedure, and that the signee understands fully. It requires the signature of both the medical staff and the signee to validate the consent or non-consent.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    PEMERINTAH KABUPATEN WONOSOBO

    DINAS KESEHATAN
    UPTD PUSKESMAS SELOMERTO 1
    Jl. Banyumas Km. 7 Telp. (0286) 324306kodepos56361

    SURAT PERNYATAAN SETUJU / TIDAK SETUJU TERHADAP TINDAKAN MEDIK

    Saya yang bertandatangan di bawahini :


    Nama :
    Umur :
    Alamat :
    DenganIniMenyatakanSesungguhnyaTelahMemberikanPersetujuan /
    TidakSetujuUntukDilakukanTindakanMedis …………………………………..
    TerhadapDiriSayaSendiri / Istri / Suami / Anak / Ayah / Orang Tua / Saudara:
    Nama :
    Umur :
    Alamat :
    No CM :
    Yang Tujuan / Sifat Dan PerlunyaTindakanMedisTersebut Di Atas Serta Resiko Yang
    Ditimbulkannya, TelahDijelaskanOlehDokter / Dokter Gigi / Perawat / Perawat Gigi / Bidan ,
    Dan SayaTelahMemahamiSepenuhnya.

    Selomerto,…………………………
    .
    Petugas Yang MembuatPernyataan

    (………………………) (…………………………..)

    PEMERINTAH KABUPATEN WONOSOBO


    DINAS KESEHATAN
    UPTD PUSKESMAS SELOMERTO 1
    Jl. Banyumas Km. 7 Telp. (0286) 324306kodepos56361

    SURAT PERNYATAAN SETUJU / TIDAK SETUJU TERHADAP TINDAKAN MEDIK

    Saya yang bertandatangan di bawahini :


    Nama :
    Umur :
    Alamat :
    DenganIniMenyatakanSesungguhnyaTelahMemberikanPersetujuan /
    TidakSetujuUntukDilakukanTindakanMedis …………………………………..
    TerhadapDiriSayaSendiri / Istri / Suami / Anak / Ayah / Orang Tua / Saudara :
    Nama :
    Umur :
    Alamat :
    No CM :
    Yang Tujuan / Sifat Dan PerlunyaTindakanMedisTersebut Di Atas Serta Resiko Yang
    Ditimbulkannya, TelahDijelaskanOlehDokter / Dokter Gigi / Perawat / Perawat Gigi / Bidan ,
    Dan SayaTelahMemahamiSepenuhnya.

    Selomerto,…………………………
    .
    Petugas Yang MembuatPernyataan

    (………………………) (…………………………..)

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