PEMERINTAH KABUPATEN LEMBATA

RUMAH SAKIT UMUM DAERAH LEWOLEBA

Jl. TRANS LEMBATA No. Telp.08533367608
F a x . ( 0 3 8 3) 2 3 4 34 4 2
E - M A I L : r s ud . l e w o l e b a @ y a ho o . c o . i d

FORMULIR KOMPLAIN / SARAN

Kepada Yth,
Direktur RSUD Lewoleba
di Tempat

Yang bertanda tangan dibawah ini :

Nama : .................................................................................................
Jenis Keamin : .................................................................................................
Pekerjaan : .................................................................................................
Alamat : .................................................................................................
.....................................................................................................................................................................
No. Telpon : ........................................................................................
Bersama ini disampaikan saran/keluhan kami mengenai pelayanan RSUD Lewoleba tentang hal-hal
yang dialami oleh kami sendiri/keluarga dan pasien :
Nama : ....................................................................................................
Dirawat/berobat di poliklinik : ..............................................
Mengenai hal : ................................................................................................................
Kronologis keluhan : ...............................................................................................................
Saran / Harapan : ..............................................................................................................

Terima Kasih atas perhatiannya

Lewoleba, ...................................
Hormat Kami

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