Formulir permohonan cuti perawatan pasien revisi.docx

 LAMP.

RS PKU MUHAMMADIYAH WONOSOBO

CUTI PERAWATAN PASIEN Saya yang bertanda tangan dibawah ini :  Nama

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Umur

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Ruang Perawatan : ....................................................... ............................................................................... ................................................ ............................................... ......................... .. Alamat Cuti : ............................................ .................................................................... ............................................... ............................................... .............................................. ...................... Telp.

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Dengan ini mengajukan permohonan cuti perawatan : ................................................... ................................................... ( waktu cuti ). Dengan alasan : ......................................... ................................................................. ............................................... ............................................... .............................................. ...................... Wonosobo,

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JAWABAN PERSETUJUAN DOKTER PENANGGUNG JAWAB

Saya yang bertanda tangan dibawah ini : Dokter

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Jabatan

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Dengan ini menyatakan bahwa permohonan cuti perawatan perawat an disetujui : ............................................ ............................................ ............... (waktu cuti). Dengan alasan : .............................................. ...................................................................... ............................................... .......................

Wonosobo,

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