8/18/2019 formulir bayi

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LEMBAR SERAH TERIMA BAYI

PETUGAS KE ORANG TUA / KELUARGA

Yang bertenda tangan dibawah ini :

 Nama :.................................................................(Dokter / Perawat / Bidan / PRS*)

Ruang :.................................................................(RSU.Auia / !n"tan"i #ainn$a.........................**)

%en$erahkan ba$i&

'eada&

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

Aamat :.................................................................

 No. !dentita" :.................................................................

 No. e :.................................................................

ubungan dengan ba$i : ( Baak / !bu / 'akek / Nenek / ++++++.)

%embawa "urat kua"a ,ikabukan orang tua (- $a )%embawa bukti Photo o$ Surat nikah dan "urat keterangan keahiran (- $a )

Bitar&++++++..0++

  Petuga" Petuga" Sak"i

$ang men$erahkan $ang menerima

  (++++++++) (++++++++) (+++++++..)

R% :

 Nama :........................(#/P)g #ahir/Umur :...........................h

Aamat :...............................(%ohon dii"i atau diteme "ti1ker abe identita" ,ika ada )

8/18/2019 formulir bayi

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SURAT PERSETUJUAN PENGAMBILAN BAYI

Yang bertanda tangan dibawah ini  Nama :................................................

angga #ahir/Umur :.........................................(#/P)

Aamat :................................................

:................................................

 No. e/P :................................................

 No. !dentita" 'P/S!% :................................................

ubungan dengan ba$i :A$ah/!bu/................................

Terhada! Ba"i

R% :

 Nama :........................(#/P)

g #ahir/Umur :...........................h

Aamat :...............................(%ohon dii"i atau diteme "ti1ker abe identita" ,ika ada )

Yang bertanda tangan dibwah ini :

#$ Ji%a ba"i &'dah dii(in%an !')ang *)eh +PJP *rang t'a a%an diberitah' *)eh !et'ga& dan

dii(in%an ,e,bawa !')ang ba"i &ete)ah ,en"e)e&ai%an ad,ini&tra&i !')ang$

-$ Han"a *rang t'a ba"i

a. A$ah

 Nama (#engka) :..................................................................................

angga ahir/umur :..................................................................................

Aamat :..................................................................................

:..................................................................................

 No .e/P :..................................................................................

 No. !dentita" 'P/S!% :..................................................................................

 b. !bu

 Nama (#engka) :..................................................................................

angga ahir/umur :..................................................................................Aamat :..................................................................................

:..................................................................................

 No .e/P :.................................................................................. No.!dentita" 'P/S!% :..................................................................................

.$ Ji%a *rang t'a berha)angan ,a%a *rang t'a ,ewa%i)%an !enga,bi)an ba"i dari RSU

A')ia Ke!ada

 Nama (#engka) :..................................................................................

angga ahir/umur :..................................................................................

Aamat :..................................................................................

:..................................................................................

 No .e/P :..................................................................................

 No. !dentita" 'P/S!% :..................................................................................

ubungan dg ba$i :..................................................................................

$ Penga,bi)an ba"i dengan ,e,bawa

- Surat engantar engambian ba$i

- 'artu identita" 'P/ Surat nikah / Surat keahiran- Pada Point 2 di"ertai "urat kua"a dari orang tua ba$i

Bitar&..........................0.......

3rang tua Petuga"

  ( ....................................) (....................................)  td 4 Nama erang td 4 Nama erang