Formulir Berita Acara Penyelesaian Komplain

BERITA ACARA PENYELESAIAN KOMPLAIN PASIEN ATAU KELUARGA PASIEN

 Nama Lengkap*  Nama Pasien* Hubungan dengan Pasien Alamat Telepon/ HP* Waktu Terjadi Komplain Komplain

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

Berita acara penyelesaian komplain

*(Wajib di isi)

Sibolga, Sibolga, …….……….20 Yang Menyelesaikan Komplain

Keluarga/Pasien

(……………………..……………..)

(…………….……………………..)

 Nama Jelas & Tanda Tangan

 Nama Jelas & Tanda Tangan