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BERITA ACARA KOMPLAIN PASIEN

RUMAH SAKIT UNIVERSITAS BRAWIJAYA


Nomor : _____________________________

Yang bertanda tangan di bawah ini ,


Nama :
Jenis Kelamin : Laki Laki Perempuan
Pekerjaan :
Alamat :
No Telp / HP : ( )- / HP +62
Bersama dengan ini disampaikan saran/keluhan kami mengenai pelayanan Rumah Sakit
Universitas Brawijaya tentang hal-hal yang dialami oleh kami sendiri/keluarga dari pasien.
Kronologis / komplain
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Penanganan Komplain
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Dengan ini saya telah memahami segala penjelasan yang telah diberikan oleh
petugas dan saya bersedia untuk komplain ini di proses sesuai dengan prosedur
penanganan komplain Rumah Sakit Universitas Brawijaya.

Malang,
2017

Petugas Pasien / Keluarga Pasien

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