FORMULIR TINDAK LANJUT PENYAMPAIAN KELUHAN PASIEN

Nama Pasien : ...................................................................................

No. Rekam Medis : ...................................................................................
No. HP : ...................................................................................
Alamat : ...................................................................................
Tanggal Kejadian : ...................................................................................
Tanggal Komplain diterima : ...................................................................................
Asal Pengaduan : ...................................................................................
Isi Pengaduan : ...................................................................................
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Tindak Lanjut : ...................................................................................
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Jakarta, 2019

Mengetahui yang membuat

Plt. Direktur RSUD Kemayoran Pengelola Humas dan Pemasaran

drg. Alifianti Lestari, M.Si. Pratama Naim

NIP 196807141992122001
 FORMULIR KOMPLAIN DAN SARAN
RUMAH SAKIT UMUM DAERAH KEMAYORAN

Kepada Yth.

Direktur RSUD Kemayoran

Yang bertanda tangan di bawah ini :

Nama : .............................................................................................

Jenis Kelamin : .............................................................................................

Alamat : .............................................................................................

No. Telp/HP : .............................................................................................

Bersama ini kami sampaikan keluhan/saran kami mengenai pelayanan di RSUD

Kemayoran, tentang hal-hal yang dialami oleh kami sendiri/keluarga dan pasien:

Nama : ......................................................................

Dirawat/Berobat di Poliklinik : ......................................................................

Mengenai/Hal : ......................................................................

Kronologi Keluhan : ......................................................................

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Saran : ......................................................................

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Jakarta, 2019
Hormat Saya,

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