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  • FORM INFOMd CONSENTD

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    Gea Rinni
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    This document is a consent form from Klinik Pratama Mulia Jaya Seva clinic located in Bali, Indonesia. It collects information such as the patient's name, date of birth, gender, ID number, and identifies the doctor performing the procedure. The form lists 10 types of information to be discussed including diagnosis, treatment procedure, risks, complications and alternatives. Spaces are provided for the doctor and patient to sign acknowledging the information was received and understood.

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    This document is a consent form from Klinik Pratama Mulia Jaya Seva clinic located in Bali, Indonesia. It collects information such as the patient's name, date of birth, gender, ID number, and identifies the doctor performing the procedure. The form lists 10 types of information to be discussed including diagnosis, treatment procedure, risks, complications and alternatives. Spaces are provided for the doctor and patient to sign acknowledging the information was received and understood.

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    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    5 views2 pages

    FORM INFOMd CONSENTD

    Uploaded by

    Gea Rinni
    This document is a consent form from Klinik Pratama Mulia Jaya Seva clinic located in Bali, Indonesia. It collects information such as the patient's name, date of birth, gender, ID number, and identifies the doctor performing the procedure. The form lists 10 types of information to be discussed including diagnosis, treatment procedure, risks, complications and alternatives. Spaces are provided for the doctor and patient to sign acknowledging the information was received and understood.

    Copyright:

    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    KLINIK PRATAMA MULIA JAYA SEVA

    Jl. Raya seririt-Gilimanuk Desa Sumberkima Kecamatan Gerokgak Buleleng-Bali


    Post code 81155, mobile phone : 081338049000 (whatsapp);
    Email :muliajayaseva@gmail.com

    FORMULIR PERSETUJUAN TINDAKAN KEDOKTERAN

    No. RM : ..............................
    Nama : ................................
    PERSETUJUAN TINDAKAN KEDOKTERAN
    Tanggal Lahir : ................................
    (INFOMED) Jenis Kelamin : L/P
    NIK : ................................

    Identitas penerima informasi jika bukan pasien


    Dokter Pelaksana
    Nama : ..........................................................
    Tanggal lahir : ............................................
    1. .................................
    Hub. dengan pasien : ...........................................................
    Alamat : ...................................................
    Jenis Kelamin : L/P

    JENIS
    NO ISI INFORMASI TANDA (V)
    INFORMASI

    1. Diagnosis
    2 Dasar Diagnosis
    3 Tindakan
    Kedokteran
    4 Indikasi Tindakan
    5 Tata Cara
    6 Tujuan
    7 Risiko
    8 Komplikasi
    9 Prognosis
    10 Alternatif & Risiko
    Lain-lain
    Dengan ini menyatakan bahwa telah menerangkan hal-hal diatas Nama dan Tanda
    secara benar dan memberikan kesempatan untuk bertanya dan / tangan
    atau berdiskusi
    (.........................)
    Dengan ini menyatakan bahwa saya telah menerima informasi Nama dan Tanda
    sebagaimana diatas yang saya beri tanda/paraf di kolom tangan
    kanannya, dan telah memahaminya
    (.........................)
    KLINIK PRATAMA MULIA JAYA SEVA
    Jl. Raya seririt-Gilimanuk Desa Sumberkima Kecamatan Gerokgak Buleleng-Bali
    Post code 81155, mobile phone : 081338049000 (whatsapp);
    Email :muliajayaseva@gmail.com

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