RM.

28

Nama Pasien : ...................................... No. RM :

Jenis Kelamin: L / P Tgl Lahir : ........................../.......

Thn / Bln / Hr

Ruang / Unit : ......................................

FORMULIR PERSETUJUAN TRANSFUSI
Alamat : ......................................................... .......................................................
Yang bertanda tangan di bawah ini :
Nama : ....................................................................................................................................
Umur : ....................................................................................................................................
Hubungan : Pasien / Ayah / Ibu / Anak / Suami / Istri / Lain-lain
(Mohon disebutkan)
Alamat : ....................................................................................................................................
No. Telepon/HP : ....................................................................................................................................
Setelah mendapatkan penjelasan dari dokter tentang beberapa hal dibawah ini :
Indikasi / manfaat transfusi
Resiko transfusi
Cara / prosedur transfusi

Dengan ini menyatakan SETUJU dilakukan tindakan transfusi terhadap pasien :

Nama : ..........................................................................................................................
Ruangan : ..........................................................................................................................
No. Rekam Medis : ..........................................................................................................................
Umur/Jenis Kelamin : ................................................................................................. Thn / ( L / P )*
Alamat : ..........................................................................................................................
..........................................................................................................................

Natar, ............................. Dokter

Yang membuat pernyataan

(...................................................) (...................................................)
Nama Jelas Nama Jelas

Saksi I Saksi II

(...................................................) (...................................................)
Nama Jelas Nama Jelas