FORMULIR PERMINTAAN PELAYANAN KEROHANIANYang bertandatangan di bawah iniNama :..........................................................................................................................................................Umur :..........................................................................................................................................................Alamat :..........................................................................................................................................................Hubungan dengan pasien:...................................................................................................................

Dengan ini menyatakan permintaan pendampingan pelayanan kerohanian agama/ kepercayaan....................................................................................................................................................Kepada Rumah Sakit Elizabeth terhadap pasien:Nama :..........................................................................................................................................................No.RM:..........................................................................................................................................................Umur :..........................................................................................................................................................Alamat :..........................................................................................................................................................

Demikian surat permohonan permintaan pelayanan kerohanian saya buat atas perhatiannya saya ucapkan terima kasih

Situbondo, - - Saksi Yang menyetujui

(...............................) (.............................)