Form Peminjaman Rekam Medis

 

]uhcohc ]lehd Dli`s

ZLDCBHDHC ]LEHD DLI@[

 Chdh Zhs`lc

2

Ca ]D

 Chdh Zld`cbhd

2

Fhcth` / E`c`e

2

Yhcoohf/ Bhd Z`cbhd

2

]lckhch Zlcoldmhf`hc 2

Hfhshc Zld`cbhdhc *) 2

Yhcoohf/ Bhd Eldmhf` 2

Yhcih Yhcohc &

Yhcih Yhcohc &

2

 C  Chhdh Flcoehp

2

2

Chdh Flcoehp

 N`fl yhco i`p`cbhd ghrhp i`eldmhf`ehc el ]uhcohc ]lehd Dli`s ihfhd whetu 8x=9 bhd, elkuhf` elkuhf` uctue ehsus egusus *dagac uctue i``s` hfhshc pld`cbhdhc slkhrh tlrplr`ck`.

]uhcohc ]lehd Dli`s

ZLDCBHDHC ]LEHD DLI@[

 Chdh Zhs`lc

2

 Chdh Zld`cbhd

2

Fhcth` / E`c`e

2

Yhcoohf/ Bhd Z`cbhd

2

]lckhch Zlcoldmhf`hc 2

Hfhshc Zld`cbhdhc *) 2

Yhcoohf/ Bhd Eldmhf` 2

Yhcih Yhcohc &

Yhcih Yhcohc &

2

 C  Chhdh Flcoehp

Ca ]D

2

2

Chdh Flcoehp

 N`fl yhco i`p`cbhd ghrhp i`eldmhf`ehc el ]uhcohc ]lehd Dli`s ihfhd whetu 8x=9 bhd, elkuhf` elkuhf` uctue ehsus egusus *dagac uctue i``s` hfhshc pld`cbhdhc slkhrh tlrplr`ck`.