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LEMBAR SERAH TERIMA BAYI PETUGAS KE ORANG TUA / KELUARGA Yang bertenda tangan dibawah ini :  Nama :............................ .......................... ...........(Dokter / Perawat / Bidan / PRS*) Ruang Ruang :............. :..................... ................ ................ ................ ................ ................ ............(RS ....(RSU.Au U.Auia ia / !n"tan"i !n"tan"i #ainn$a. #ainn$a.......... ................. ...............* .......**) *) %en$erahkan ba$i&

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 Nama :.................... :........................(#/P ....(#/P)) g #ahir/Umur #ahir/Umur :....... :........... ........ ........ ........ ........ ....h h Aamat :............................... (%ohon dii"i atau diteme "ti1ker abe identita" ,ika ada )

'eada&  Nama :.......................... .......................... ............. Aam Aamat at :... :..... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ..  No. !dentita" :.......................... .......................... .............  No. e e :.......................... .......................... ............. ubungan dengan ba$i : ( Baak / !bu / 'akek 'akek / Nenek / ++++++.) %embawa "urat kua"a ,ikabukan orang tua %em %embawa awa buk buktti Ph Photo o$ o$ Sura Suratt nik nikah ah dan "ura "uratt ket keteerang rangan an keah eahir iran an

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SURAT PERSETUJUAN PENGAMBILAN BAYI Yang bertanda tangan dibawah ini   Nama :................................................ angga #ahir/Umur :.........................................(#/P) Aamat :................................................ :................................................  No. e/P :................................................  No. !dentita" 'P/S!% :................................................ ubungan dengan ba$i :A$ah/!bu/................................

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 Nama :........................(#/P) g #ahir/Umur :...........................h Aamat :............................... (%ohon dii"i atau diteme "ti1ker abe identita" ,ika ada )

Yang bertanda tangan dibwah ini : #$ Ji%a ba"i &'dah dii(in%an !')ang *)eh +PJP *rang t'a a%an diberitah' *)eh !et'ga& dan dii(in%an ,e,bawa !')ang ba"i &ete)ah ,en"e)e&ai%an ad,ini&tra&i !')ang$ -$ Han"a *rang t'a ba"i  a. A$ah  Nama (#engka) :............................. .......................... ........................... angga ahir/umur :.................................................................................. Aamat :.................................................................................. :..................................................................................  No .e/P :............................. .......................... ...........................  No. !dentita" 'P/S!% :............................. .......................... ...........................  b. !bu  Nama (#engka) angga ahir/umur Aamat

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.$ Ji%a *rang t'a berha)angan ,a%a *rang t'a ,ewa%i)%an !enga,bi)an ba"i dari RSU A')ia Ke!ada   Nama (#engka) :............................. .......................... ........................... angga ahir/umur :.................................................................................. Aamat :.................................................................................. :..................................................................................  No .e/P :............................. .......................... ...........................  No. !dentita" 'P/S!% :............................. .......................... ........................... ubungan dg ba$i :.................................................................................. $ Penga,bi)an ba"i dengan ,e,bawa  - Surat engantar engambian ba$i - 'artu identita" 'P/ Surat nikah / Surat keahiran - Pada Point 2 di"ertai "urat kua"a dari orang tua ba$i

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