RUMAH SAKIT PERMATA BUNDA

JL. SOEKARNO HATTA NO. 75 MALANG

TELP. (0341) 487487 / 407462 Fax. (0341) 474242
Email : rs_permatabunda@yahoo.co.id

FORMULIR KOMPLAIN / SARAN

Yth, Direktur RS. PERMATA BUNDA

Yang bertanda tangan di bawah ini :
Nama : ........................................................................................................
Jenis Kelamin :.........................................................................................................
Pekerjaan : ........................................................................................................
Alamat : ........................................................................................................
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No. Telp/HP : ........................................................................................................
bersama ini disampaikan saran / keluhan kami mengenai pelayanan RS. Permata Bunda
tentang hal-hal yang dialami oleh kami sendiri / keluarga dari pasien :

Nama : .....................................................................................
Dirawat / berobat di Poliklinik : .....................................................................................
Mengenai /Hal : .....................................................................................
Kronologis keluhan : .....................................................................................
Saran / harapan : .....................................................................................
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Malang
Hormat kami,

 Rahasia Jabatan dipegang penuh

(*) Pasien/Keluarga Pasien/Pelanggan
 RUMAH SAKIT PERMATA BUNDA
JL. SOEKARNO HATTA NO. 75 MALANG
TELP. (0341) 487487 / 407462 Fax. (0341) 474242
Email : rs_permatabunda@yahoo.co.id

FORMULIR PERTANYAAN

Nama : ....................................................................................................................
Jenis Kelamin :.....................................................................................................................
Pekerjaan : ....................................................................................................................
Alamat : ....................................................................................................................
....................................................................................................................
No. Telp/HP : ....................................................................................................................
Keterangan lain (*) : ....................................................................................................................
Mengajukan pertanyaan sebagai berikut :
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Malang,
Hormat Kami,

 Rahasia Jabatan dipegang penuh

(*) Pasien/Keluarga Pasien/Pelanggan