FORM KRONOLOGIS PESERTA KEJADIAN TRAUMA

Nama :
No. Kartu :
No. TELP/HP :
Alamat :
Status Pekerjaan :
Tanggal dan jam kejadian :
Lokasi Kejadian :
Rincian Kronologis
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Dengan ini saya menyatakan saya bahwa informasi yang sampaikan diatas adalah benar dan saya
bertanggung jawab mutlak secara hukum jika dikemudian hari terbukti keterangan saya tersebut adalah
keterangan palsu.
Mengetahui Tanjung Enim,
Dokter Pemeriksa Saksi Yang Membuat Pernyataan
Materai 6000

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RS. BUKIT ASAM MEDIKA

JL. Raya Bukit Asam No.118 Tanjung Enim, Indonesia
Telp : +62734451204
Fax : +62734453134