RM.FO.01.Rev02.

2020

RSU Famili Husada

Jl. Astina Timur No. 8 A Samplangan Gianyar Bali
Telp. 0361-8493344

IDENTITAS PASIEN

Identitas Pasien
Nama (Sesuai KTP) : ....................................................................................................
Tempat / Tanggal Lahir : ....................................................................................................
NIK : ....................................................................................................
No. RM : ....................................................................................................
Jenis Kelamin : Laki-laki Perempuan
Kewarganegaraan :  WNI  WNA
Agama : ....................................................................................................
Pendidikan : ....................................................................................................
Pekerjaan : ....................................................................................................
Alamat KTP : ....................................................................................................
Alamat Tinggal : ....................................................................................................
No.Telp / HP : ....................................................................................................
Jaminan Kesehatan : ....................................................................................................

Nama Penanggung Jawab : ....................................................................................................

Hubungan dengan Pasien : ....................................................................................................
No.Telp / Hp : ....................................................................................................

Gianyar, .................................................
Pasien / Penanggung Jawab

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