Pemerintah Provinsi Sulawesi Tengah

Rumah Sakit Daerah Madani

FORMULIR PENYELESAIAN KELUHAN PASIEN

Saya yang bertanda tangan dibawah ini, sebagai ............................................................... :

Nama : .............................................................

Jabatan di RSD Madani : .............................................................

Alamat / No. HP : .............................................................

Dengan ini saya menyampaikan jawaban atas keluhan pasien / keluarga pasien :

Nama : .............................................................

Umur / Tanggal Lahir : .............................................................

Alamat / No. HP : .............................................................

No. Rekam Medis : .............................................................

Bahwa : ...................................................................................................

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Demikian penyelesaian keluhan ini kami sampaikan, semoga dapat diterima dengan baik.

Pihak Rumah Sakit,

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