PERSETUJUAN TINDAKAN MEDIK

( INFORMED CONSENT )

Saya yang bertanda tangan di bawah ini:

Nama : ______________________________________________________

Umur/Jenis Kelamin : __________________________/Laki-laki/Perempuan*

Alamat : ______________________________________________________

Bukti diri/KTP : ______________________________________________________

Menyatakan dengan sesungguhnya telah memberikan

PERSETUJUAN

Untuk dilakukan tindakan medik berupa: __________________________________________

Terhadap diri saya sendiri*/Anak*/Isteri*/Suami*/Ayah*/Ibu* saya dengan

Nama : ______________________________________________________

Umur/Jenis Kelamin : __________________________/Laki-laki/Perempuan*

Alamat : ______________________________________________________

Diagnosa : ______________________________________________________

Nomor Rekam Medik : ______________________________________________________

Yang tujuan, sifat dan perlunya tindakan medik tersebut di atas, serta risiko yang dapat ditimbulkannya dan upaya
mengatasinya telah cukup dijelaskan oleh dokter dan telah saya mengerti sepenuhnya.

Demikian persetujuan ini saya buat dengan penuh kesadaran dan tanpa paksa.

Lalanglinggah,

Yang Membuat Pernyataan Saksi I Saksi II

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 INFORMED CONSENT OF MEDICAL ACTION/TREATMENT

( INFORMED CONSENT )

I who signed under this :

Name : ______________________________________________________

Age/Gender : __________________________/Male/Female*

Address : ______________________________________________________

Identity Number : ______________________________________________________

Hereby declare

CONSENT

To receive a medical action/treatment in form of __________________________________________

To Myself*/My Child*/Wife*/Husband*/Father*/Mother* by:

Name : ______________________________________________________

Age/Gender : __________________________/Male/Female*

Address : ______________________________________________________

Diagnose : ______________________________________________________

Medical Report Number : ______________________________________________________

The purpose, nature/procedure and necessity of the medical action/treatment that mentioned above, as well as the risks it
can cause and the effort to ovecome, it have been sufficiently explained by the doctor and I fully understand.

Thus I made this consent with full awareness and without being forced.

Lalanglinggah,

That makes the statement 1st Witnness 2nd Witnness

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