FORMULIR PEMINJAMAN BERKAS REKAM MEDIS

Data File
Nama pasien dan nomor RM : 1. ( )
2. ( )
3. ( )
4. ( )
5. ( )
Data Peminjam
Nama :.......................................................................................................
Unit yang meminjam :.......................................................................................................
Keperluan peminjaman :.......................................................................................................
Tanggal peminjaman :.......................................................................................................
Lama peminjaman :.......................................................................................................
Persetujuan
Peminjam Yang Meminjamkan