RSD HUSADA BORNEO

Jl. A. Yani Km.30,5 No 4 Banjarbaru Kal-Sel 70721

Telp. (0511) 4784900

Formulir Bimbingan Rohani Pasien

Telah dilakukan bimbingan rohani pasien sesuai dengan agama dan keyakinan oleh :

Nama : ...........................................................................L/P Umur............th

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

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

Ruangan : ..........................................................................................................

Agama : Islam Kristen Katolik Hindu Budha

Kong Hu Cu

Petugas Admisi / Perawat ……., ………..,20…

Pasien / Keluarga pasien

(…………………………..) (…………………………..)

HASIL BIMBINGAN ROHANI

Banjarbaru, ....................................

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Petugas Bimbingan Rohani

(…………………………..)