8/16/2019 Surat Penyataan ANC

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NAMA FASKES: ...................................................................................................................

...

NAMA DOKTER: ...................................................................................................................

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PEMBERI PELAYANAN: ...................................................................................................................

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ALAMAT : .......................................................................................................................

TELEPON : .......................................................................................................................

Yang bertanda tangan di bawah ini :

NAMA : .......................................................................................................................

ALAMAT : ........................................................................................................................

........................................................................................................................

TELEPON : .........................................................................................................................

Adalah bertinda !ebagai diri !a"a#$rang t%a#!%a&i# el%arga'dari (a!ien:

NAMA : .........................................................................................................................

NOMOR KART): ....................................................................................................................

.....)M)R : .........................................................................................................................

ALAMAT : .........................................................................................................................

TELEPON : .........................................................................................................................

Dengan ini &en"ata an ber!edia#tida eberatan' %nt% :

8/16/2019 Surat Penyataan ANC

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*. Mela % an (e&eri !aan !ela&a eha&ilan +(e&eri !aan AN,- !e!%aidengan etent%an (ada !at% a!ilita! e!ehatan ting at (erta&a +&ini&al/0 (e&eri !aan (ada * +!at%- ali (ada tri!e&e!ter (erta&a eha&ilan 1*+!at%- ali (ada tri!e&e!ter ed%a eha&ilan1dan 2 +d%a- ali(adatri!e&e!ter etiga eha&ilan.

2. Menda(at (ela"an (e&eri !aan eha&ilan +(e&eri !aan AN,- di a! e!r%3% an ting at lan3%t diberi an berda!ar an indi a!i &edi! (e!erta.

De&i ian (ern"ataan ini a&i b%at1agar da(at di(erg%na an !e(erl%n"a.

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Bidan Pela !ana "ang &e&b%at(ern"ataan1

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