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  • Informed Consent

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    Fitria ananda
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    This document is a consent form from the Juai Community Health Center in Balangan Regency, Indonesia. It states that a patient, their guardian, spouse, child, or representative is consenting to or declining a medical procedure. The form includes spaces for names, gender, date of birth, address, and medical record number. It also has a section for the doctor performing the procedure and witnesses to sign, indicating the patient understands the explanation provided about their illness, the procedure, and possible outcomes.

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    informed consent

    Original Title

    INFORMED CONSENT

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    This document is a consent form from the Juai Community Health Center in Balangan Regency, Indonesia. It states that a patient, their guardian, spouse, child, or representative is consenting to or declining a medical procedure. The form includes spaces for names, gender, date of birth, address, and medical record number. It also has a section for the doctor performing the procedure and witnesses to sign, indicating the patient understands the explanation provided about their illness, the procedure, and possible outcomes.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views3 pages

    Informed Consent

    Uploaded by

    Fitria ananda
    This document is a consent form from the Juai Community Health Center in Balangan Regency, Indonesia. It states that a patient, their guardian, spouse, child, or representative is consenting to or declining a medical procedure. The form includes spaces for names, gender, date of birth, address, and medical record number. It also has a section for the doctor performing the procedure and witnesses to sign, indicating the patient understands the explanation provided about their illness, the procedure, and possible outcomes.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    PEMERINTAH KABUPATEN BALANGAN

    DINAS KESEHATAN PENGENDALIAN PENDUDUK DAN KB

    UPT. PUSKESMAS JUAI


    Alamat : Jl. Setia Karsa No.50 Mungkur Uyam Kec. Juai Kab. Balangan 71665

    SURAT PERSETUJUAN/PENOLAKANTINDAKAN MEDIS


    (INFORMED CONSENT)

    Saya yang bertanda tangan di bawah ini :


    Nama :
    Jenis Kelamin :
    Tanggal Lahir :
    Alamat :

    Menyatakan dengan sesungguhnya dari saya sendiri/*orangtua*/*suami*/*istri*/*anak*/*wali


    Dari :
    Nama :
    Jenis Kelamin :
    Tanggal Lahir :
    Alamat :
    Nomor RM :

    Dengan ini menyatakan SETUJU/MENOLAK untuk dilakukan tindakan medis berupa


    ...........................................................................................................................................
    Dari penjelasan yang di berikan, saya mengerti segala hal yang berhubungan dengan penyakit tersebut, serta tindakan
    medis yang akan di lakukan dan kemungkinan pasca tindakan yang dapat terjadi sesuai penjelasan yang diberikan.

    Juai, 2023
    Dokter yang merawat
    Yang membuat pernyataan,
    (...............................)

    (...............................)
    Saksi,

    (...............................)
    PEMERINTAH KABUPATEN BALANGAN
    DINAS KESEHATAN PENGENDALIAN PENDUDUK DAN KB

    UPT. PUSKESMAS JUAI


    Alamat : Jl. Setia Karsa No.50 Mungkur Uyam Kec. Juai Kab. Balangan 71665

    SURAT PERSETUJUAN/PENOLAKANTINDAKAN MEDIS


    (INFORMED CONSENT)

    Saya yang bertanda tangan di bawah ini :


    Nama :
    Jenis Kelamin :
    Tanggal Lahir :
    Alamat :

    Menyatakan dengan sesungguhnya dari saya sendiri/*orangtua*/*suami*/*istri*/*anak*/*wali


    Dari :
    Nama :
    Jenis Kelamin :
    Tanggal Lahir :
    Alamat :
    Nomor RM :

    Dengan ini menyatakan SETUJU/MENOLAK untuk dilakukan tindakan medis berupa


    ...........................................................................................................................................
    Dari penjelasan yang di berikan, saya mengerti segala hal yang berhubungan dengan penyakit tersebut, serta tindakan
    medis yang akan di lakukan dan kemungkinan pasca tindakan yang dapat terjadi sesuai penjelasan yang diberikan.

    Juai, 2023
    Dokter yang merawat
    Yang membuat pernyataan,
    (...............................)

    (...............................)
    Saksi,

    (...............................)

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