PERNYATAAN PERSETUJUAN PEMBERIAN INFORMASI MEDIS

RELEASE OF MEDICAL INFORMATION CONSENT FORM

Saya dengan ini memberikan otorisasi kepada dokter, paramedik petugas kesehatan yang ditunjuk oleh
Lamina Pain and Spine Center sebagai perwakilan dari klinik ataupun rumah sakit, ataupun orang yang
melakukan pemeriksaan terhadap saya, untuk memberikan informasi medis yang dibutuhkan kepada

Nama : ………………………………………………………………………………………………………..

Alamat : …………………………………………………………………………………………………………

Hubungan dengan Pasien : ………………………………………………………………………………………………………….

maupun pihak terkait lainnya berkaitan dengan kondisi kesehatan, cedera, riwayat medis sebelumnya,
hasil konsultasi, pengobatan maupun catatan medis yang saya alami untuk digunakan sebagaimana
mestinya.

I hereby give an authorization to doctor, paramedic or any other health officer on duty chosen by
Lamina Pain and Spine Center as a representative for the clinic or hospital, or a person that did a medical
examination to me, to release my medical information that needed to other personnel regarding my
health condition, injury, past medical history, any result of consultation, past medication or any medical
condition recorded to be used respectfully.

Fotokopi dari dokumen ini dianggap sah dan sama dengan aslinya.
The of this document will be assumed valid and same with the original.

Nama Pasien/Patient’s Name : Tanda Tangan Pasien/Patient’s Signature :

........................................................... ……………………………………………………………

Tanggal/Date :

............................................................ ……………………………………………………………

Alamat/Address :

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

…………………………………………………………

The information contained in this message is the property of PT. SEJAHTERA BERKAH MEDIKA or its affiliates and may be confidential and is intended only for the use of the addressee(s).

No addressee should forward, print, copy, or otherwise reproduce this message in any manner that would allow it to be viewed by any individual not originally listed as a recipient. If
the reader of this message is not the intended recipient, you are hereby notified that any unauthorized disclosure, dissemination, distribution, copying or the taking of any action in
reliance on the information herein is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message.