FORMULIR KELUHAN PASIEN/KELUARGA

RSU HKBP BALIGE

Rawat Jalan :
Rawat Inap :

Nama Pasien : .......................................

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Telepon : .......................................
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Jam : .......................................

Kronologis Kejadian :

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Kritik/Keluhan/Saran :

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Balige, tgl.
Tertanda

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Hubungan ke Pasien : ..............................................................
 LAPORAN EVALUASI TINDAK LANJUT KELUHAN PASIEN/KELUARGA
BULAN : ............................... 2022

NO KELUHAN TINDAK LANJUT

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Mengetahui Dilaporkan
Direktur RSU HKBP Balige Kabid Pemasaran dan Pelayanan Pelanggan

Dr. Benni Sinaga, Sp.B Harry Siagian, SE