FORMULIR

PERMOHONAN PELAYANAN DETEKSI CA SERVIX (PAP SMEAR/IVA)

Saya yang bertanda tangan di bawah ini :

Nama : .........................................................................................................

Tempat Tanggal Lahir : .........................................................................................................

Jenis Kelamin : .........................................................................................................

Status Pernikahan : .........................................................................................................

Nomor Peserta BPJS : .........................................................................................................

Pendidikan Terakhir : .........................................................................................................

Instansi / Badan Usaha / PBPU : .........................................................................................................

Alamat Rumah : .........................................................................................................

.........................................................................................................

No. Telp Rumah / HP : .........................................................................................................

E-Mail : .........................................................................................................

Keluarga yang bisa dihubungi : .........................................................................................................

Nama : .........................................................................................................

Alamat Rumah : .........................................................................................................

.........................................................................................................

No. Telp Rumah / HP : .........................................................................................................

E-Mail : .........................................................................................................

.........................................................................................................

Dengan sadar dan atas keinginan memohon kepada BPJS Kesehatan untuk menerima pelayanan
Pemeriksaan Deteksi Ca servix atas diri saya. Sehubungan dengan permohonan tersebut,
dengan ini saya menyatakan kesediaan atas data kesehatan diri saya untuk dipergunakan oleh
Dokter, dan BPJS Kesehatan dalam rangka analisa kesehatan.

Sukadamai, 20

Yang membuat pernyataan

(..........................................................................)
Peserta BPJS Kesehatan
(PAP SMEAR/IVA)

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menerima pelayanan
onan tersebut,
dipergunakan oleh

20

t pernyataan

...................................)
Kesehatan