RSUD dr. R.

Koesma Kabupaten Tuban

Jl. Dr. Wahidin Sudiro Husodo No. 800
Telp. (0356) 321010, 325696 NO LOKER :

FORMULIR PENITIPAN BARANG MILIK PASIEN

Yang bertanda tangan di bawah ini, saya :

Nama penitip : ...........................................................................................................................................
Nama pasien : ...........................................................................................................................................
Alamat : ...........................................................................................................................................
No.KTP/I.d. lain : ...........................................................................................................................................
Pada hari ini : ......................................... Tgl ........... Bln ................................ Th ...............................
Menitipkan barang berupa :
1. ......................................................................................................., Kondisi .....................................
2. ......................................................................................................., Kondisi .....................................
3. ......................................................................................................., Kondisi .....................................
4. ......................................................................................................., Kondisi .....................................
5. ......................................................................................................., Kondisi .....................................

Petugas, Yang menitipkan,

______________________ _____________________

Tanggal pengambilan : .................................................................................................................

Nama pengambil : .............................................................................................................................
Alamat : .............................................................................................................................
No. KTP/I.d lain : .............................................................................................................................
Barang yang diambil :
1. ................................................................., Sudah diambil Kondisi ........................................
2. ................................................................., Sudag diambil Kondisi ........................................
3. ................................................................., Sudah diambil Kondisi ........................................
4. ................................................................., Sudah diambil Kondisi ........................................
5. ................................................................., Sudah diambil Kondisi ........................................

Petugas, Yang mengambil,

______________________ ______________________

 potong disini

Lembar Tanda Terima Bukti Penitipan No. LOKER

Telah menitipkan barang di Ruang : _____________________
Nama Pasien : ....................................................................................................................................
Nama Penitip : ...................................................................................................................................
No.KTP/Id. lain : ...................................................................................................................................
Jenis barang :
1. ..................................................................................................................................................................
2. ..................................................................................................................................................................
3. ..................................................................................................................................................................
4. ..................................................................................................................................................................
5. ..................................................................................................................................................................
Barang sudah diambil : Hari /tanggal /Th............................................, Jam ..................................................

Yang menitipkan,
Petugas,

______________________ ______________________