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Lembar perjanjian evakuasi medis

Instalasi Gawat Darurat RSUD A.W. Sjahranie Samarinda


Jl.Palang Merah Indonesia Telp. (0541) 738118 (Hunting System) Fax
(0541) 741772
Kepada,
Yth, ................................................
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Di tempat
Identitas Pasien
Nama
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Umur
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Agama
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Pekerjaan :
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Alamat
:
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Keluhan Utama/Riwayat Penyakit

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Tanda-tanda vital
Tekanan Darah :................................
Scale :...................................
Nadi

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:...................................

Pernapasan
Suhu

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:...................................

Glasgow Coma
SpO2
Nyeri

:................................

Diagnosa

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Penatalaksanaan Terapi

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Dokter yang Menangani

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Petugas Ruangan

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Lembar perjanjian evakuasi medis


Instalasi Gawat Darurat RSUD A.W. Sjahranie Samarinda
Jl.Palang Merah Indonesia Telp. (0541) 738118 (Hunting System) Fax
(0541) 741772

SURAT PERNYATAAN

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Umur

Alamat
No. KTP/SIM

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:

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diatas dari dokter / perawat .................................................... Bersedia ditranspor
oleh Ambulans Gawat Darurat IGD RSUD A.W. Sjahranie Samarinda dan menerima
segala resiko terburuk yang mungkin terjadi terhadap pasien selama perjalanan
dan setelah tiba di tempat tujuan.

Samarinda, .............................................2015
Yang membuat pernyataan

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