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    3.1.1 EP b.3 FORMAT INFORMED CONSENT

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    Rifda Nurfadilah
    This document is an informed consent form from the Cimanggu Public Health Center in Pandeglang Regency. It states that the undersigned patient understands and consents/does not consent to medical treatment procedures such as IV infusion, injections, catheterization, suturing, wound care, nebulization, oxygen administration, or blood draws for lab tests. The patient confirms they understand the nature, purpose, and potential risks of the procedures as explained by the healthcare provider. The form is signed by the patient and witnesses and will be used appropriately.

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    3.1.1 EP b.3 FORMAT INFORMED CONSENT

    Uploaded by

    Rifda Nurfadilah
    7 views3 pages
    This document is an informed consent form from the Cimanggu Public Health Center in Pandeglang Regency. It states that the undersigned patient understands and consents/does not consent to medical treatment procedures such as IV infusion, injections, catheterization, suturing, wound care, nebulization, oxygen administration, or blood draws for lab tests. The patient confirms they understand the nature, purpose, and potential risks of the procedures as explained by the healthcare provider. The form is signed by the patient and witnesses and will be used appropriately.

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    FORMAT INFORMED CONSENT

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    © © All Rights Reserved

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    This document is an informed consent form from the Cimanggu Public Health Center in Pandeglang Regency. It states that the undersigned patient understands and consents/does not consent to medical treatment procedures such as IV infusion, injections, catheterization, suturing, wound care, nebulization, oxygen administration, or blood draws for lab tests. The patient confirms they understand the nature, purpose, and potential risks of the procedures as explained by the healthcare provider. The form is signed by the patient and witnesses and will be used appropriately.

    Copyright:

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

    3.1.1 EP b.3 FORMAT INFORMED CONSENT

    Uploaded by

    Rifda Nurfadilah
    This document is an informed consent form from the Cimanggu Public Health Center in Pandeglang Regency. It states that the undersigned patient understands and consents/does not consent to medical treatment procedures such as IV infusion, injections, catheterization, suturing, wound care, nebulization, oxygen administration, or blood draws for lab tests. The patient confirms they understand the nature, purpose, and potential risks of the procedures as explained by the healthcare provider. The form is signed by the patient and witnesses and will be used appropriately.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 3

    PEMERINTAH KABUPATEN PANDEGLANG

    DINAS KESEHATAN
    UPT PUSKESMAS CIMANGGU
    Jl. Raya Cibaliung-Sumur KM 12, Lingkar Utara Polos Cimanggu 42284
    HOTLEN : WA/SMS 085814704312 email:puskesmas.cimanggu1@gmail.com

    PERSETUJUAN TINDAKAN MEDIK


    (INFORMED CONSENT)

    Yang bertanda tangan dibawah ini:


    Nama : …………………………………………………………………..
    Umur : …………………………………………………………………..
    Jenis Kelamin : Laki- laki / Perempuan
    Nomor KTP/ SIM : …………………………………………………………………..
    Alamat lengkap : …………………………………………………………………..
    Untuk : Diri Sendiri/ orang tua/ suami/ Istri/ lain- lain

    Nama : …………………………………………………………………..
    Umur : …………………………………………………………………..
    Jenis Kelamin : Laki- laki / Perempuan
    Nomor KTP/ SIM : …………………………………………………………………..
    Alamat lengkap : …………………………………………………………………..

    Dengan ini menyatakan sesungguhnya bahwa saya telah memberikan PERSETUJUAN/


    PENOLAKAN *) untuk dilakukan tindakan medik perawatan : Pemasangan Infus/ Injeksi Obat/
    Kateterisasi/ penjahitan/ perawatan luka/ nebulizer/ pemasangan oksigen/ pengambilan
    sampel darah untuk pemeriksaan laboratorium, yang mana sifat dan tujuan tindakan serta
    kemungkinan bias timbulnya akibat- akibatnya telah dijelaskan sepenuhnya oleh petugas
    kesehatan yang bersangkutan dan telah saya mengerti sepenuhnya.

    Demikian pernyataan ini dibuat, dengan sadar dan tanpa paksaan pihak manapun agar dapat
    dipergunakan sebagaimana mestinya.

    Cimanggu,....................2023
    Pukul..................................WIB
    Mengetahui,
    Disetujui Oleh, Dokter/ Perawat yang Merawat

    …………………………… …………………………………….
    Saksi 1 Saksi 2

    …………………………… ……………………………

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