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RUMAH SAKIT ISLAM LUMAJANG

Jl. Kyai Muksin 19, Lumajang 67302


Telp. (0334)887999, 893535 (hunting), Fax : (0334)890425 e-mail : rsi_lmj@yahoo.com

Ijin Operasional Dinas Kesehatan Kab. Lumajang Akreditasi nNasional 5 Pelayanan


Tanggal : 28 Oktober 2014 Tanggal : 06 Juli 2011
Nomor : 188.45/336/427.12/2014 Nomor : KARS-SERT/15/VII/2011

Permintaan Pelayanan Kerohanian

Identitas pasien : ..........................................................................................................................


Tanggal Lahir : ......................................................................................... no : ...........................
RM : ............................................................................................................................
Agama : ................................................................................................................
Permintaan Tanggaj/Jam : ......................................................... / ........................................
Konfirmasi petugas Kerohanian : ....................................................... / ..............................
Nama Petugas Kerohanian : ....................................................................................................
Tanggal / Jam kedatangan : ....................................................................................................
No. Telp / No. Hp : ....................................................................................................

Lumajang, tgl ...................................................


Tandatangan Tandatangan

Perawat Pasien / Keluarga