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Nama pasien : ....................................

No. Rekam Medis : ....................................


Rumah Sakit
Umum Mitra Sejati

FORMULIR HAK DAN KEWAJIBAN/TANGGUNG JAWAB PASIEN

Tanda tangan dan


Nama Jelas
Tgl/
Materi edukasi
Jam Keluarga
Pasien Staf RS
(Hubungan)

Dijelaskan tentang Hak dan


Tanggung Jawab Pasien:
1. Dijelaskan dan ditujukan Lembar
Informasi Hak dan
Kewajiban/Tanggung Jawab
Pasien Rawat Inap di Rumah Sakit
umum mitra sejati

2. Pertanyaan Pasien:
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3. Tanggapan Pemberi Informasi:


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