Nama : ............................................ Umur : ............................................ No. Hp : ............................................. Alamat : ............................................. Selaku ayah/ ibu/ anak/ saudara, dari : Nama : .............................................. Umur : .............................................. No. Hp : .............................................. Alamat : .............................................. Hal hal yang dikomplainkan* : __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Penyelesaian komplain : __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ * Komplain akan dilayani oleh pihak rumah sakit apabila ada bukti tertulis atau melalui sms. Komplain akan diselesaikan min 1x24 jam dengan adanya pihak pasin rumah sakit.