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

No.RM : ................................................

Tanggal Lahir : ................................................

FORM PENUNDAAN PELAYANAN

Tanggal : .................................................................................................................

Ruang Rawat / Instalasi : ................................................................................................................

Diagnosa : .................................................................................................................

DPJP : .................................................................................................................

Tim Dokter : 1. ............................................................................................................

2. .............................................................................................................

3. .............................................................................................................

Kondisi Terakhir Pasien : .................................................................................................................

Alasan Penundaan Pasien

1. Medis : .................................................................................................................
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2. Non Medis : .................................................................................................................
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Rencana Pelayanan Lanjutan : .................................................................................................................
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Dengan ini menyatakan bahwa saya telah Penerima Informasi

menerima informasi sebagaimana diatas
dan telah memahaminya

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