Nama :…………………………………………………………………………..
No. Rekam Medis :…………………………………………………………………………..
Keperluan :…………………………………………………………………………..
..…………………………………………..……………………………..
Nama Peminjam :…………………………………………………………………………..
Tanggal Pinjam :…………………………………………………………………………..
( ) ( ) ( )
Ka. Unit / Ruang Rekam Medis
Form Peminjaman
Berkas Rekam Medis
Nama :…………………………………………………………………………..
No. Rekam Medis :…………………………………………………………………………..
Keperluan :…………………………………………………………………………..
..…………………………………………..……………………………..
Nama Peminjam :…………………………………………………………………………..
Tanggal Pinjam :…………………………………………………………………………..
( ) ( ) ( )
Ka. Unit / Ruang Rekam Medis