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Rumah Sakit PMC No.

RM :
PEKANBARU MEDICAL CENTER Nama :
Tgl Lahir :
Jl. Lembaga Pemasyarakatan No. 25 Gobah Pekanbaru Jenis Kelamin :
Telp. (0761) 848100, 859510 Fax. (0761) 85951

FORMULIR PENYELESAIAN KOMPLAIN, KELUHAN, KONFLIK ATAU


PERBEDAAN PENDAPAT

Nama pasien/keluarga :

Tanggal lahir :

Tanggal/Jam Komplain :

Ruangan/bagian :

URAIAN MASALAH :

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Penerima komplain

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TINDAKAN PENYELESAIAN KOMPLAIN

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Yang Menyelesaikan

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Rumah Sakit PMC No. RM :
PEKANBARU MEDICAL CENTER Nama :
Tgl Lahir :
Jl. Lembaga Pemasyarakatan No. 25 Gobah Pekanbaru Jenis Kelamin :
Telp. (0761) 848100, 859510 Fax. (0761) 85951

EVALUASI/TINDAK LANJUT:

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