WIDYA MANDALA HOSPITAL

Jl. Kalisari Selatan 1, Pakuwon City Surabaya

INFORMED CONSENT FOR NURSING ROUND AGREEMENT

Patient Identity
Name :
Regitrtation Number :
Birth :
Address :
Phone :
PATIENT OR PATIENT GUARDIAN MUST BE READ, UNDERSTAND
AND FILL THIS INFORMED CONSENT
Whose signature here,
Name :
Address :
Phone :
As a patient or patient guardian in Widya Mandala Hospital said agree/ disagree
with …………………….........................................................................................
And I understand with all the benefit or risk of this therapy.

Surabaya,

Primary Nurse Patient/Guardian

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