COST AND PAYMENT AGREEMENT

I, The undersigned below :

Name :

Age : Gender : M/F

Address in Indonesia (Hotel) :

Address (as in I*d Card) :

Id Card Number : (Passport / Kitas)

With this I agreed to give a permission to :

Do the medical treatment such as :

Laboratory Check : Cost :

Transfusion Package : Cost :

Medicine : Cost :

Radiology Check : Cost :

Others : Cost :

Through my self/spouse/wife/husband/child/father/mother with,

Name :

Age : Gender : M/F

Address (as in Id Card) :

That the purpose and importance of this agreement to be done, have clearly understandable and
responsibly taken by myself, especially for the payment or cost of the treatment.

I signed this letter with full awareness as informed by the medical staff/team, without any force.

Mataram, .../…/…. Time ..:..

Administration Witnesses Who make the statement

1. Family 2. Nurse

………………….. …………………… ……………………..