sorn02015 ‘Questionnaire Report You are logged in as Emirul Swadesi Evhani (Logout) My home b My courses b Academic ® Undergraduate b Data Pasien RS UCM ® General ® PERSETUJUAN UMUM / ‘GENERAL CONSENT ® Questionnaire Report b Your Results Administration View Your responses- view 1 View Default order View By Response All your responses Course administration 'y Resp your respi My profile setings Your 1 response(s) DATA IDENTITAS PASIEN RS UGM 1 | Nama Lengkap © Response 1 anil Swades vant 2 | Tempat/ Tanggal Lahr + Response 1 Steman (23 Apri 1997 3 | Alamat © Response 1 Karangaser RT‘03 RW 36 Wedomartani Ngemplak Sleman Yogyakarta 4 PERSETUJUAN UMUM GENERAL CONSENT Response Average Total Dengan inisava near NN 255 1 bafta saya akan mentaat peraturan yang ada di RS UGM ( Hereby declare that) will obey all regulation a UGM Hospi. Dengan ini saya neryaan TN 25% 1 setuju untuk dilacukan emeriesaan | tindakan yang Ciperiukan dalam uoaya Keseruhan / Keselamatan wa saya / pasien tersbut datas, Hereby agree to do inspection / necessary medical treatment i order o healing | safety of my Soul / patient mentioned above ). Syamenseri sa kepada TD 25% 1 lokter yang merawat saya untuk memberikan keterangan mess Saya kepada pihak yang bertanggung Jawa ats biaya perawatan saya Authorize the Fp llgamol kcugm ac.idimoalquestomairalmyropor phprinsiance=1708user=21251sorn02015 ‘Questionnaire Report physician who treated me to give Iimedical ceriiete to the person responsible for the cost of my Saya seta identas saya es 1 slnfarmasikan kepada Fakulas Kedokteran UCM. (Agree my identity to be informed to Faults Kedokteran UCM) 5 Yogyakarta, i ) No responses for this question. 1 are logged in as Emirul Swadesi Evnani (Logout) Fp llgamol hcugm ac.idimoalquestomairalmyropor phprinsiance=1708user=21251