FORM PERMOHONAN CUTI RAWAT INAP

Saya/ yang bertanggung jawab terhadap pasien meminta kepada pihak RSUD Dayaku Raja
untuk mengijinkan kepada pasien:
Nama :...............................................................................................
Umur/ Tgl. Lahir :...............................................................................................
No. RM : ..............................................................................................
Rawat di Ruang :...............................................................................................
Untuk ijin pulang sementara/ cuti perawatankarena kepentingan:
......................................................................................................................................................
..............................................................................................................................................
Dalam kurun waktu.................. hari (tanggal).............................s/d.......................................
Jam (pukul)........................s/d..........................................

Selama berada di luar RSUD Dayaku Raja yang bertanggung jawab terhadap pasien adalah:
Nama :...................................................................................................
No. KTP/ SIM :...................................................................................................
Hubungan dengan Pasien:...................................................................................................
Selama berada di luar Rumah Sakit beralamat di:
......................................................................................................................................................
No . Telp./ HP pasien :...................................................................................................
No. Telp./HP penanggung jawab:...............................................................................................

Kota Bangun ......./....../.....................

Pemohon

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