PRIMA MEDIKA HOSPITAL in Pla soon Te WIth Quality aie Hospitality! Ssrangan No. 9X Oenpasar Ball Telp (0364) 288025, Fee (0% Emad -rpm@ioainstia Weosie wmmugnmmresioce SURATPERNVATAAN PULANG ATAS : LANG ATAS PERMINTAAN SEN LEAVING AGAINTS MEDICAL ADVICE ro ‘Yang bertands tansan dibawal ii J, the undersign Be Nama Mejfsikap / } Unmur 53 | age denis Kelamin AE Ue RO mata. 65 Pensala- fo DPS Memb: Malang this statementfor myself\iifeushandipathen nor | Sins > AyMade fend ayrettn” Umur 26 Age Jenis Kelamin : PE etsy a (CCE M hcp C4 Pumas 10 Alamat address Dirawat di RS Prima Medika Room No Prima Medika Hospital | Bahwa memang benar meminta pulang atas permintuan sendiri dari RS Prima Medika. | Pris wrue that I ask to be discharged from Prima Medika Hospital upon my request. | Scgala sesuatu yang terjadi setelah keluar dari RSU Prima Medika bukan lagi menjadi tanggungjawab | RSU Prima Medika dan dokter yang merawat. | Anything that might kappen since the discharge from Prima Medika Hospital will not be Prima Medika | Hospital's responsibility so does the treating doctor. 4- 20td Saksi-Saksi Witnesses Keluarga Pihak RSU Prima Medika Family G Nama/Name