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RUMAH SAKIT NIRMALA SURI RUMAH SAKIT NIRMALA SURI

JL. Raya Solo – Sukoharjo KM. 9 JL. Raya Solo – Sukoharjo KM. 9
Telp. (0271) 592192, 593814 Telp. (0271) 592192, 593814
Fax (0271) 590084 Fax (0271) 590084
Kode Pos 57527 Kode Pos 57527
FORMULIR PERMINTAAN PELAYANAN KEROHANIAN FORMULIR PERMINTAAN PELAYANAN KEROHANIAN

Ruang : ........................................................................................... Ruang : ...........................................................................................


No. RM : ........................................................................................... No. RM : ...........................................................................................
Nama / Umur : ........................................................................................... Nama / Umur : ...........................................................................................
Agama : ........................................................................................... Agama : ...........................................................................................
Alamat : ........................................................................................... Alamat : ...........................................................................................
Meminta pelayanan kerohanian berupa : Meminta pelayanan kerohanian berupa :
a. Bimbingan agama dan do’a a. Bimbingan agama dan do’a
b. Dukungan moril dan motivasi psikologis b. Dukungan moril dan motivasi psikologis
c. Konsultasi keluarga c. Konsultasi keluarga
d. Lain – lain : ........................................................................................... d. Lain – lain : ...........................................................................................
Sukoharjo, ......................................... Sukoharjo, .........................................
Yang Meminta Yang Meminta

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