PEMERINTAH PROPINSI DAERAH KHUSUS IBUKOTA JAKARTA

DINAS KESEHATAN
Jalan Kesehatan Nomor 10 Telepon: 021-3451338, 021-3800154 Faksimili 021-3451342
JAKARTA
Kode Pos : 10160

PERSETUJUAN TINDAKAN MEDIS

Saya yang bertanda tangan dibawah ini :

Nama : ..........................................................................................
Umur/Jenis Kelamin : ..........................................................................................
Alamat : ..........................................................................................
Bukti Diri/KTP : ..........................................................................................
Menyatakan dengan sesungguhnya telah memberikan
PERSETUJUAN / PENOLAKAN *

Untuk dilakukan tindakan medis berupa ;

Terhadap diri saya sendiri / Istri / Suami / Ayah / Ibu saya dengan
Nama : ..........................................................................................
Umur/Jenis Kelamin : ..........................................................................................
Alamat : ..........................................................................................
Yang tujuan, sifat dan perlunya tindakan medis tersebut diatas, serta risiko
yang dapat ditimbulkanya dan upaya mengatasinya telah cukup jelas oleh
dokter dan telah saya mengerti sepenuhnya.
Demikian persetujuan ini saya buat dengan penuh kesadaran dan tanpa
paksaan

Jakarta, ............................... 2019

Dokter pemeriksa Yang membuat pernyataan

( .........................................) ( .........................................)

Saksi 1 Saksi 2

( .........................................) ( .........................................)
 PEMERINTAH PROPINSI DAERAH KHUSUS IBUKOTA JAKARTA
DINAS KESEHATAN
Jalan Kesehatan Nomor 10 Telepon: 021-3451338, 021-3800154 Faksimili 021-3451342
JAKARTA
Kode Pos : 10160

Kepada
Yth. Kepala / Direktur Rumah Sakit
.........................................................
di-
Jakarta

Bersama ini kami kirim pasien :

Nama : ..........................................................................................
Umur/Jenis Kelamin : ..........................................................................................
Alamat : ..........................................................................................
Petugas Pengirim : ..........................................................................................
Nomor Handphone : ..........................................................................................

Diagnosa
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

Riwayat Kejadian
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

Tindakan Yang Telah diberikan

.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

Mohon dapat dilakukan pengobatan / tindakan selanjutnya. Atas perhatian dan

kerjasamanya diucapkan banyak terima kasih.

Jakarta, ........................................... 2019

Petugas Kesehatan

( ..................................................... )
 PEMERINTAH PROPINSI DAERAH KHUSUS IBUKOTA JAKARTA
DINAS KESEHATAN
Jalan Kesehatan Nomor 10 Telepon: 021-3451338, 021-3800154 Faksimili 021-3451342
JAKARTA
Kode Pos : 10160

STATUS PASIEN
Kegiatan :
Tanggal :
Lokasi :

Nama :
Umur :
Alamat :

ANAMNESA :

PEMERIKSAAN :
FISIK

DIAGNOSA :

THERAPI :

Nama & Paraf Petugas

(...........................................)