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YAYASAN UNIVERSITAS ISLAM MALANG

RUMAH SAKIT ISLAM MALANG


Jl. MT. Haryono 139 Malang 65144, Telp. (0341) 551356, 565448, 580798 Fax. (0341) 551257, 577205 E-mail : rsi_unisma@yahoo.com

FORMULIR PERMINTAAN PELAYANAN KEROHANIAN


Dengan ini saya / keluarga pasien meminta ketersediaan pelayanan rohani kepada :
Nama pasien : ................................................................................................
Nomor RM : ................................................................................................
Tanggal Lahir / Umur : ................................................................................................
Jenis Kelamin : ................................................................................................
Agama : ................................................................................................
Ruang Rawat Inap : ................................................................................................
Permintaan Tanggal / Jam : ................................................................................................
Nama Petugas Kerohanian : ................................................................................................
Tanggal / Jam Kedatangan : ................................................................................................
Nomor Telepon / Hp : ................................................................................................

Malang, .................................................
Perawat Pasien / Keluarga

(....................................) (....................................)
Tanda Tangan & Nama Terang Tanda Tangan & Nama Terang

YAYASAN UNIVERSITAS ISLAM MALANG


RUMAH SAKIT ISLAM MALANG
Jl. MT. Haryono 139 Malang 65144, Telp. (0341) 551356, 565448, 580798 Fax. (0341) 551257, 577205 E-mail : rsi_unisma@yahoo.com

FORMULIR PERMINTAAN PELAYANAN KEROHANIAN


Dengan ini saya / keluarga pasien meminta ketersediaan pelayanan rohani kepada :
Nama pasien : ................................................................................................
Nomor RM : ................................................................................................
Tanggal Lahir / Umur : ................................................................................................
Jenis Kelamin : ................................................................................................
Agama : ................................................................................................
Ruang Rawat Inap : ................................................................................................
Permintaan Tanggal / Jam : ................................................................................................
Nama Petugas Kerohanian : ................................................................................................
Tanggal / Jam Kedatangan : ................................................................................................
Nomor Telepon / Hp : ................................................................................................

Malang, .................................................
Perawat Pasien / Keluarga

(....................................) (....................................)
Tanda Tangan & Nama Terang Tanda Tangan & Nama Terang