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  • RM 12 Rev

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    jeje roji
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    This document is a statement of consent for a patient to be discharged from the Puskesmas Arjasa health center. It includes spaces for the name, gender, age, address, and relationship to the patient of the person making the statement. The statement asserts that the family agrees the patient currently being treated at Puskesmas Arjasa is in good/critical condition and will be brought home. It acknowledges the family is aware of and accepts all risks in taking the patient from the health center.

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    RM 12

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    RM 12 rev

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    This document is a statement of consent for a patient to be discharged from the Puskesmas Arjasa health center. It includes spaces for the name, gender, age, address, and relationship to the patient of the person making the statement. The statement asserts that the family agrees the patient currently being treated at Puskesmas Arjasa is in good/critical condition and will be brought home. It acknowledges the family is aware of and accepts all risks in taking the patient from the health center.

    Copyright:

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

    RM 12 Rev

    Uploaded by

    jeje roji
    This document is a statement of consent for a patient to be discharged from the Puskesmas Arjasa health center. It includes spaces for the name, gender, age, address, and relationship to the patient of the person making the statement. The statement asserts that the family agrees the patient currently being treated at Puskesmas Arjasa is in good/critical condition and will be brought home. It acknowledges the family is aware of and accepts all risks in taking the patient from the health center.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    No.

    RM :
    PEMERINTAH KABUPATEN SUMENEP
    Nama Lengkap :
    RM 12
    DINAS KESEHATAN
    Tanggal Lahir : L/P
    PUSKESMAS ARJASA Alamat :

    SURAT PERNYATAAN PULANG PAKSA

    Saya yang bertanda tangandi bawah ini :

    Nama : …………………………………………………………………………
    Jenis Kelamin : …………………………………………………………………………
    Umur : …………………………………………………………………………
    Alamat : …………………………………………………………………………
    Hubungan dengan Pasien : …………………………………………………………………………

    Menyatakan bahwa kami sekeluarga sepakat yang dirawat di Puskesmas Arjasa meyakini
    saat ini dalam kondisi Baik / kondisi kritis *) dan selanjutnya untuk dibawa pulang.

    Demikian Surat Pernyataan kami buat dengan penuh kesadaran tanpa paksaan dan siap
    menanggung dengan segala risiko yang ada.

    Arjasa, Tgl…………………..20 Jam :


    Mengetahui
    Petugas Jaga Puskesmas Arjasa Yang Membuat Pernyataan

    (………………………………) (………………………………)

    Saksi I Saksi II

    (………………………………) (………………………………)

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