RUMAH SAKIT IBU DAN ANAK BUNDA NONI PALEMBANG

Jln. Srijaya Negara Rt. 072 Rw. 011 Kel. Bukit Lama Kec. Ilir Barat I Palembang
Sumatera Selatan Telp. (0711) 441952

FORMULIR PENGAJUAN KOMPLAIN / SARAN

Yth. Direktur Utama

RSIA Bunda Noni di Tempat,

Yang bertanda tangan di bawah ini:

Nama :__________________________________________________
Pekerjaan :__________________________________________________
Alamat :__________________________________________________
No. Identitas :__________________________________________________
No. Telpon :__________________________________________________
Menyampaikan saran/keluhan terhadap pelayanan RSIA Bunda Noni terhadap diri
saya/suami/istri/anak/orang tua/saudara* yang beridentitas:
Nama :__________________________________________________
No. Med. Record :__________________________________________________
Ruang Perawatan :__________________________________________________

Kronologis Keluhan
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Saran dan Harapan

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Palembang, ___/____/20_______

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*Coret yang tidak perlu