Bukti Pelaksanaa Info Consent
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PEMERINTAH KABUPATEN
PEMERINTAH KABUPATEN WONOSOBO DINAS KESEHATAN UPTD PUSKESMAS PUGUK Jln. Raya Bengkulu- Manna Kelurahan puguk KM. 69. Kab Seluma 38576 PUSKESMAS
SELUMA
PUGUK KABUPATEN SELUMA
BUKTI PELAKSANAAN INFORMED CONSENT N o
Ta ng gal
No. RM
Nama Pasien
Diagnosa
Nama Petugas
Nama Penerima Info consent
Hubungan Dengan Pasien
Keterang an
TT D
PEMERINTAH KABUPATEN WONOSOBO DINAS KESEHATAN UPTD PUSKESMAS PUGUK Jln. Raya Bengkulu- Manna Kelurahan puguk KM. 69. Kab Seluma 38576 PUSKESMAS
SELUMA
PUGUK KABUPATEN SELUMA
BUKTI PELAKSANAAN INFORMED CONSENT N o
Ta ng gal
No. RM
Nama Pasien
Diagnosa
Nama Petugas
Nama Penerima Info consent
Hubungan Dengan Pasien
Keterang an
TT D
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