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KETERANGAN TELAH BIMBINGAN ROHANI / SPIRITUAL

Nama Pasien Lengkap

Tanggal Lahir Pasien

Jenis Kelamin Pasien

No Rekam Medis

Keterangan Pembimbing Rohani

<p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Saya yang bertanda tangan di bawah ini :</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Nama <span style="white-space:pre">			</span>:…………………………………………………………………..................................</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif"><br></font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Telah memberikan bimbingan rohani kepada pasien :</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Nama <span style="white-space:pre">			</span>:………………………………………………………………………………………..</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Tanggal lahir <span style="white-space:pre">		</span>:………………………………………………………………………………………..</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Jenis Kelamin <span style="white-space:pre">	</span>:  Laki-laki/Perempuan*</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Dirawat di ruang <span style="white-space:pre">	</span>:………………………………………………………………………………………..</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Agama <span style="white-space:pre">			</span>: □ Islam     □ Kristen Protestan      □ Katolik    □ Buddha       □ Hindhu   *)                                                                                                                                     </font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Telah dilakukan bimbingan kerohanian berupa ................................................................................<span style="white-space:pre">	</span> </font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Demikian surat keterangan ini saya buat.</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif"><br></font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif"><br></font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Tebing Tinggi, Tgl .............…………. Jam .........….. WIB</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Pembimbing Rohani</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif"><br></font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif"><br></font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">(………………………………………..)</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Tanda tangan dan Nama Jelas</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif"><br></font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">Catatan :</font></p><p class="MsoNormal" style="line-height:150%"><font face="Times New Roman, serif">*) Coret yang tidak perlu</font></p>

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