11. Form Inform Concent Tranfusi.doc
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RSUD dr. FAUZIAH BIREUEN JLN. T HAMZAH BENDAHARA NO. 13
Nama Pasien
: ......................................
Jenis Kelamin: L / P
No. RM
:
Tgl Lahir : ........................../.......
Thn / Bln / Hr
TRANSFUSI Tgl DARAH RuangPERSETUJUAN / Kelas : ...................................... Masuk : ................................... Yang bertanda tangan di Jam bawah ini : : ............ Nama
: ....................................................................................................................................
Umur
: ....................................................................................................................................
Hubungan
: Pasien / Ayah / Ibu / Anak / Suami / Istri / Lain-lain* .............................................. (Mohon disebutkan)
Alamat
: ....................................................................................................................................
No. Telepon/ HP : .................................................................................................................................... Setelah mendapatkan penjelasan dari dokter tentang beberapa hal dibawah ini : Indikasi / manfaat transfusi Resiko transfusi Cara / prosedur transfusi Dengan ini menyatakan SETUJU dilakukan tindakan transfusi darah terhadap pasien : Nama
: ..........................................................................................................................
Ruangan
: ..........................................................................................................................
No. Rekam Medis
: ..........................................................................................................................
Umur/Jenis Kelamin
: ................................................................................ Thn / Bln/ Hari ( L / P )*
Alamat
: .......................................................................................................................... .......................................................................................................................... Bireuen, ................................ Jam : ...........
Yang membuat pernyataan
(...................................................) Tanda Tangan & Nama Terang Saksi I
(...................................................) Tanda Tangan & Nama Terang
*) Coret yang tidak perlu
Dokter
(...................................................) Tanda Tangan & Nama Terang Saksi II
(...................................................) Tanda Tangan & Nama Terang
Nama Pasien
: ......................................
Jenis Kelamin: L / P
No. RM
:
Tgl Lahir : ........................../.......
Thn / Bln / Hr
TRANSFUSI Tgl DARAH RuangPERSETUJUAN / Kelas : ...................................... Masuk : ................................... Yang bertanda tangan di Jam bawah ini : : ............ Nama
: ....................................................................................................................................
Umur
: ....................................................................................................................................
Hubungan
: Pasien / Ayah / Ibu / Anak / Suami / Istri / Lain-lain* .............................................. (Mohon disebutkan)
Alamat
: ....................................................................................................................................
No. Telepon/ HP : .................................................................................................................................... Setelah mendapatkan penjelasan dari dokter tentang beberapa hal dibawah ini : Indikasi / manfaat transfusi Resiko transfusi Cara / prosedur transfusi Dengan ini menyatakan SETUJU dilakukan tindakan transfusi darah terhadap pasien : Nama
: ..........................................................................................................................
Ruangan
: ..........................................................................................................................
No. Rekam Medis
: ..........................................................................................................................
Umur/Jenis Kelamin
: ................................................................................ Thn / Bln/ Hari ( L / P )*
Alamat
: .......................................................................................................................... .......................................................................................................................... Bireuen, ................................ Jam : ...........
Yang membuat pernyataan
(...................................................) Tanda Tangan & Nama Terang Saksi I
(...................................................) Tanda Tangan & Nama Terang
*) Coret yang tidak perlu
Dokter
(...................................................) Tanda Tangan & Nama Terang Saksi II
(...................................................) Tanda Tangan & Nama Terang
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