LAMP.

RS PKU MUHAMMADIYAH WONOSOBO

CUTI PERAWATAN PASIEN

Saya yang bertanda tangan dibawah ini :

Nama :................................................................................................................................
Umur :................................................................................................................................
Ruang Perawatan :................................................................................................................................
Alamat Cuti :.........................................................................................................................................
Telp. :................................................................................................................................

Dengan ini mengajukan permohonan cuti perawatan :....................................................( waktu cuti ).

Dengan alasan :......................................................................................................................................

Wonosobo,

( )

JAWABAN PERSETUJUAN DOKTER PENANGGUNG JAWAB

Saya yang bertanda tangan dibawah ini :

Dokter : ..............................................................................................................................
Jabatan :...............................................................................................................................

Dengan ini menyatakan bahwa permohonan cuti perawatan disetujui :.............................................

................(waktu cuti). Dengan alasan :..............................................................................................

Wonosobo,

( )