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RS MITRA HUSADA

Jl. Raya Siliwangi No. 151 Ciawigebang – Kuningan


Telp. (0232) 878560
RS MITRA HUSADA
Jl. Raya Siliwangi No. 151 Ciawigebang – Kuningan
Telp. (0232) 878560
IDENTIFIKASI PASIEN
No. RM : ..........................................................
RS MITRA HUSADA Nama : ..........................................................
Jl. Raya Siliwangi No. 151 Ciawigebang Tgl. Lahir/ Umur/JK : .............................................. L / P *)
Kuningan Telp. (0232) 878560 Alamat : ..........................................................
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Ruang/ Kelas : .................................. / .....................

LEMBAR PERNYATAAN PERSETUJUAN (INFORMED CONSENT)

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