Format Inform Consent

LRM :

&. indakan yang diberikan •

indakan ke"erawatan

.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... •

indakan medi!

.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... •

Pemerik!aan "enun$ang medik :

.................................................................................................................................... .................................................................................................................................... •

  0alua!i

.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 1. Pa!ien "ulang -a!alah ke"erawatan yang "erlu dilan$utkan di rumah .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................

LRM :

Ke"ala ruang / tim $aga Sid#ar$#,.........................................................

)……………………………....*