Nama :
Tanggal Lahir :
No. RM :
Tanggal/Jam Komplain :
Ruangan/Bagian :
URAIAN MASALAH:
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Penerima Komplain
Telukbetung,...................Pukul.........WIB
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Pasien/Keluarga Penerima Komplain
EVALUASI/TINDAK LANJUT :