Formulir Second Opinion

RUMAH SAKIT AS-SYIFA AS-SYIFA Jl. Gerak Alam RT. RT. 13 Kelurahan Kota Medan Kecamatan Kota Manna Kabupaten Bengkulu Selatan Telp. (03!" #1$$ %ma&l ' r.a)&*a.manna+gna&l.com

Yang bertandatangan di bawah ini, a!a " Na#a

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Tg% %ahir

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 A%a#at

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Dengan ini #en!ata&an 'er#intaan nt& #enda'at e)*nd *'ini*n terhada' diri a!a endiri + a#i+ itri+ ana&+ a!ah+  ib+ wa%i +, dengan Na#a

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Tg% %ahir

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 A%a#at

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N*- MR

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Sa!a #e#aha#i 'er%n!a dan #an.aat e)*nd *'ini*n terebt ebagai#ana te%ah di/e%a&an &e'ada a!a- Sa!a te%ah #enda'at &ee#'atan nt& bertan!a dan te%ah #enda'at /awaban !ang #e#(a&an-

Sa!a /ga #en!adari bahwa *%eh &arena i%# &ed*&teran b&an%ah i%# 'ati dan e%a% ber&e#bang, #a&a 'erbedaan 'enda'at ah%i ada%ah biaa ter/adi da%a# dnia &ed*&teran- Sa!a #en!adari beban bia!a

e*nd *'ini*n #en/adi tanggng /awab a!a-

Manna, ----------------------------------------------Sa&i

Paien  0a%i++

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+) C*ret !ang tida& 'er%( ++) 1i%a 'aien tida& &*#'eten ata tida& #a #eneri#a in.*r#ai, #a&a wa%i ata ee*rang !ang diberi ha& nt& #en!et/i tinda&an terhada' 'aien tereb(t-