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  • Inform Consent

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    nuning Agustiyanawati
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    This document is a consent form from Puskesmas Sirampog in Brebes Regency, Central Java. The form provides spaces for a patient or their guardian to give consent for medical treatment, listing their name, age/gender, address and the intended treatment. It states that the doctor has explained the purpose, nature and risks of the treatment, and that consent is given voluntarily without coercion. Spaces are provided for signatures of the treating medical officer and the person giving consent.

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    persetujuan pasien

    Original Title

    inform consent

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    This document is a consent form from Puskesmas Sirampog in Brebes Regency, Central Java. The form provides spaces for a patient or their guardian to give consent for medical treatment, listing their name, age/gender, address and the intended treatment. It states that the doctor has explained the purpose, nature and risks of the treatment, and that consent is given voluntarily without coercion. Spaces are provided for signatures of the treating medical officer and the person giving consent.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    5 views3 pages

    Inform Consent

    Uploaded by

    nuning Agustiyanawati
    This document is a consent form from Puskesmas Sirampog in Brebes Regency, Central Java. The form provides spaces for a patient or their guardian to give consent for medical treatment, listing their name, age/gender, address and the intended treatment. It states that the doctor has explained the purpose, nature and risks of the treatment, and that consent is given voluntarily without coercion. Spaces are provided for signatures of the treating medical officer and the person giving consent.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    PEMERINTAH KABUPATEN BREBES PEMERINTAH KABUPATEN BREBES

    DINAS KESEHATAN DINAS KESEHATAN


    PUSKESMAS SIRAMPOG PUSKESMAS SIRAMPOG
    Jln Raya Sirampog KM 09 Kec. Sirampog 52272 Jln Raya Sirampog KM 09 Kec. Sirampog 52272
    Email :Pusk.Sirampog@gmail.com Email :Pusk.Sirampog@gmail.com

    PERSETUJUAN TINDAKAN MEDIK PERSETUJUAN TINDAKAN MEDIK

    Saya yang bertanda tangan dibawah ini saya Saya yang bertanda tangan dibawah ini saya
    sendiri*/anak*/isteri*/suami*/Ayah*/ibu* saya dari sendiri*/anak*/isteri*/suami*/Ayah*/ibu* saya dari

    Nama :................................ Nama :................................


    Umur/ jenis kelamin :................................. Umur/ jenis kelamin :.................................
    Alamat :...................................................................... Alamat :......................................................................

    Menyatakan dengan sesungguhnya telah memberikan PERSETUJUAN Menyatakan dengan sesungguhnya telah memberikan PERSETUJUAN

    Untuk dilakukan tindakan medik berupa: ............................................. Untuk dilakukan tindakan medik berupa: .............................................

    Yang tujuan,sifat dan perlunya tindakan medik tersebut diatas, serta resiko Yang tujuan,sifat dan perlunya tindakan medik tersebut diatas, serta resiko
    yang dapat ditimbulkannya dan upaya mengatasinya telah cukup dijelaskaan yang dapat ditimbulkannya dan upaya mengatasinya telah cukup dijelaskaan
    oleh dokter dan telah saya mengerti sepenuhnya.Demikian persetujuan ini saya oleh dokter dan telah saya mengerti sepenuhnya.Demikian persetujuan ini saya
    buat dengan penuh kesadaran dan tanpa paksaan buat dengan penuh kesadaran dan tanpa paksaan

    Sirampog,.....................................2021 Sirampog,.....................................2021

    Pelaksana Tindakan Yang membuat pernyataan Pelaksana Tindakan Yang membuat pernyataan

    Nama lengkap Nama lengkap Nama lengkap Nama lengkap

    *Lingkari jawaban dan coret yang tidak perlu *Lingkari jawaban dan coret yang tidak perlu
    .

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