RM 66

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

Jenis Kelamin: L / P Tgl Lahir : ............/........... Thn / Bln / Hr

RSUD dr. Sayidiman Ruang / Kelas: ............................./............ Tgl Masuk : ...................................

Magetan
Jam : ............ ............
PERMINTAAN PELAYANAN KEROHANIAN

Nama : ......................................................................... L / P*

Tanggal Lahir : ........................................../ .................... Tahun/ Bulan/

Hari

No RM : .................................................................................

Agama : ..................................................................................

Tanggal dan Jam Permintaan : ..................................................................................

Konfirmasi Petugas Kerohanian : ..................................................................................

Nama Petugas Kerohanian : .................................................................................

Tanggal dan Jam Kedatangan : .................................................................................

No. Telepon/ HP : .................................................................................

Perawat Pasien/ Keluarga

(..............................................) (..............................................)
Tanda Tangan & Nama Terang Tanda Tangan & Nama Terang