Nama :……………………………………………………

Alamat :……………………………………………………
Hari / Tanggal :……………………………………………………
No Telepon :……………………………………………………
Ruangan/Bagian :……………………………………………………
Pelapor :……………………………………………………

KELUHAN
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SARAN/HARAPAN
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Penerima Laporan Batam, ……………………

(………………) Pasien / Keluarga Pasien