REV.00.07-2019 RM.21.

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Rumah Sakit No. RM : ...................................
PERMATA HUSADA Nama :........................................... L / P
Jln Ir. Pangeran M. Noor No. 50A RT. 004 RW. 001 Kelurahan Sungai Ulin,
Kecamatan Banjarbaru Utara, Kota Banjarbaru Kalimantan Selatan
Tlp : (0511) 5912712 Tgl. Lahir :......................................(........th)

FORMULIR PENUNDAAN PELAYANAN

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Kondisi Terakhir Pasien : ...............................................................................................

Alasan Penundaan Pasien

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2. Non Medis : ...................................................................................................

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Rencana Pelayanan Lanjutan : ....................................................................................................

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