Formulir Pernyataan Pemberian Pelayanan Kerohanian.docx

RS MUJI RAHAYU Jl. Raya Manukan Wetan No. 68-68 A Surabaya- Indonesia Telp. (031) 7418889, Fax. (031) 7440449 Email : [email protected] Website : www.rsmujirahayu.com

FORMULIR PERNYATAAN PEMBERIAN PELAYANAN KEROHANIAN

Diisi oleh perawat/tim binroh Yang bertanda tangan di bawah ini: Nama

: ..............................................................................................

Tgl Lahir

: ..............................................................................................

Alamat

: ..............................................................................................

No. Telepon

: ..............................................................................................

Dengan ini menyatakan bahwa saya telah memberikan pendampingan pelayanan kerohanian terhadap, Nama

: ..............................................................................................

Tgl.lahir

: ..............................................................................................

Alamat

: ..............................................................................................

No.RM

: ..............................................................................................

Agama

: .............................................................................................

yang berisi tentang

: ...............................................................................................

................................................................................................................................................. ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Demikian surat pernyataan pemberikan pendampingan pelayanan kerohanian ini saya buat, atas perhatiannya saya ucapkan terima kasih Surabaya, ........................pkl..........

Perawat/Tim Binroh

(................................................)

Pasien/Keluarga Wali

(...................................................)

RS MUJI RAHAYU Jl. Raya Manukan Wetan No. 68-68 A Surabaya- Indonesia Telp. (031) 7418889, Fax. (031) 7440449 Email : [email protected] Website : www.rsmujirahayu.com