FORMULIR PERMINTAAN PELAYANAN KEROHANIAN

Yang bertandatangan di bawah ini

Nama
:..........................................................................................................................
................................
Umur
:..........................................................................................................................
................................
Alamat
:..........................................................................................................................
................................
Hubungan
dengan
pasien
:...................................................................................................................

Dengan ini menyatakan permintaan pendampingan pelayanan kerohanian agama/

kepercayaan.................................................................................................................
...................................
Kepada Rumah Sakit Elizabeth terhadap pasien:
Nama
:..........................................................................................................................
................................
No.RM:..........................................................................................................................
................................
Umur
:..........................................................................................................................
................................
Alamat
:..........................................................................................................................
................................

Demikian surat permohonan permintaan pelayanan kerohanian saya buat atas

perhatiannya saya ucapkan terima kasih

Situbondo,
Saksi
Yang menyetujui

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