Informed Consent-1.docx

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PEMERINTAH KABUPATEN CIANJUR AKADEMI KEPERWATAN PEMERINTAH KABUPATEN CIANJUR Jln. Pasir Gede Raya No. 19 Telp. (0263) 267206 Fax. 207953 Cianjur 43216 INFORMED CONSENT (LEMBAR PERSETUJUAN RESPONDEN)

Nama

:

Umur

:

Setelah mendapat keterangan secukupnya serta mengetahui tentang manfaat penelitian yang berjudul “Penerapan Pengaruh Mengunyah Peremen Karet Terhadap Peningkatan Peristaltik Usus Pada Klien Post Op Appendiktomi di RSUD Sayang Kelas B Cianjur”. “Saya yang bertanda tangan dibawah ini sebagai suami/istri/anak/wali menyatakan (bersedia/tidak bersedia)*

diikut sertakan dalam penelitian ini

tanpa ada paksaan”

Cianjur,

Maret 2019

Responden

___________________

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