SURAT PERNYATAAN

Yang bertanda tangan dibawh ini :

Nama : ..........................................................................................................................................
Umur : ..........................................................................................................................................
Jenis Kelamin : ..........................................................................................................................................
Alamat : ..........................................................................................................................................
No MR : ..........................................................................................................................................

Dengan ini menyatakan BERSEDIA memberi wewenang kepada Klinik Utama Jiwa Dewanta
Mental Healthcare untuk..................................................................................................................................................................................
Demikian persetujuan ini saya buat dengan penuh kesadaran dan tanpa paksaan.

Kupang, ..................................... 20....

Yang membuat pernyataan,

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