CONTOH FORMULIR PERMINTAAN PRIVASI

DiisiolehPasien/Keluarga
NAMA LENGKAP PASIEN : ...................................................... NO. RM : - Yang bertandatangan di bawahini :
Nama : .......................................................................................................................
...
Alamat : .....................................................................................................................
.....
..........................................................................................................................
NomorTelepon : ..........................................................................................................
................
HubungandenganPasien :dirisendiri / orang tua / anak / wali
*) .............................................................
1. Denganinimenyatakanbahwasaya / orang tua / anak / wali *) mengijinkan /
tidakmengijinkan *)
RumahSakitmemberiaksesbagikeluarga yang
bernama ................................................................
dankerabat yang bernama ............................................................................ serta
orang lain yang
bernama ................................................................... yang
akanmenengok/menemuisaya.

2. Sayamenginginkan / tidakmenginginkanprivasikhusus *) :
1. Padasaatwawancaraklinis
2. Padasaatpemeriksaanfisik
3. Padasaatperawatan
4. Lain-lain
Jakarta, .....................................................
Pasien/Keluarga / Wali
.................................................. ..................................................
*) Coret yang tidakperlu

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