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PEMERINTAH KABUPATEN BOGOR

RUMAH SAKIT UMUM DAERAH CILEUNGSI Jln. Raya Cileungsi – Jonggol Km.10 Cileungsi – Kab. Bogor

 Telp. (021) 8993!!" # 893!!8 $mail % rsu&l'ileungsibogorab.go.i&

PERSETUJUAN PEMBERIAN TRANFUSI DARAH

 AGGREMENT FOR BLOOD TRANSFUSIONPEMBERIAN INFORMASI

Information Delivered 

*o+er ,enanggung Ja-ab ,asien

Doctors incharge of patient 

*r.

,enerima n/ormasi#pemberi

perse+uuan

Recipient information/approved

by 

No Jenis Informasi

Information

Isi Informasi (oe! "o#$er%

Information detail (by dotor!"atatan# I$i informa$i tida% bole& men''na%an

$in'%atan

Note#Abreviation i$ not allo)ed to be $ed in

information detail 

Paraf 

Pasien&'ai

*atient+Gar 

dian Si'n

1 Tuuan pemberian &ara

 Aims of blood transfusion

2 an/aa+ pemberian &ara

The purpose of blood

transfusion

3 ,eriraan umla &arayang &iberian

Estimation of total

bloodtransfusion

Risio &an ompliasi

yang mungin +era&i

Risks and complications

that may occur 

4l+erna+i/ lain yang bisa

&ilauan +anpa +rans/usi

&araOther alternative that can

be doing without blood

transfusion

! ,eriraan biaya

Estimated cost 

" 5ain6lain

Others

•  Tin&aan +ambaan emunginan &iperluan

 ia &o+er menemuan sesua+u yang +a

+er&uga

 Additional measures may be needed if thedoctor nds something unepected

•  Tin&aan ini emunginan +i&a memberian

asil yang sesuai arapan -alaupun su&a

&ilauan sesuai s+an&ar prose&ur yang

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berlauThe action is likely not deliver results as

epected! despite being carried out

according to standard procedures

*engan ini menya+aan ba-a saya +ela menerangan al al &ia+as se'ara benar

&an elas &an memberian esempa+an un+u ber+anya &an#a+au ber&isusi

"ereby declare that # have eplained the above things are true and clear and

 provides an opportunity to ask and / or discuss

 Tan&a +angan

&o+er

$ignature

7aya su&a men&apa+an esempa+an un+u ber+anya &an saya su&a menger+i

&an puas &engan penelasan &an in/ormasi yang &iberian seubungan &engan

per+anyaan6per+anyaan saya &isamping i+u ia +era&i e'elaaan seper+i &ara

+erin/esi : &an penyai+ lainnya saya memberian i;in un+u mengambil &ara

pasien un+u +es : &an penyai+ lainnya yang penularannya melalui &ara.

 Tan&a +angan

(,asien#-ali)

$ignature

#%ve had the opportunity to ask and # already understand and are satised with the

eplanation and information given in relation to my &uestions! besides that in the

event of an accident such as blood infected with "#' and other diseases! # give you

 permission to take the patient%s blood to test for "#' and other diseases

transmission through blood(

PERSETUJUAN PEMBERIAN TRANFUSI DARAH

 AGGREEMENT FOR BLOOD TRANSFUSION

 mur # Jenis Kelamin

 Age / $e 

 5ai6lai ,erempuan

*ale +emale

4lama+

 Address

*engan ini menya+aan perse+uuan un+u % Pemerian Transf)si Dara!

These statement approval to, -iving .lood Transfusion

Ter!a"a* "iri sa+a ,&Ana#,&Is$ri,&S)ami,&A+a!,&I),&-----------sa+a.

Of *yself / 0hild/ 1ife/ "usband / +ather / *other/ *y (((((((((((((((((((((((!

)ama /Age , 22222222222222222222222222222 3mur/Age ,

222222

 4enis 5elamin/$e , 2222222222222222222222222222222222222222

 Alamat/Address , 2222222222222222222222222222222222222222

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7aya memaami perlunya &an man/aa+ +in&aan +ersebu+ sebagaimana +ela &ielasan seper+i &i

a+as epa&a saya +ermasu risio &an ompliasi yang mungin +imbul. *emiian perse+uuan ini

saya bua+ &engan penu esa&aran &an +anpa pasaan.

# understand the need for and benets of such measures as described as above to me! including the

risks and complications that may arise( $imilarly! the agreement # made with full awareness and

without coercion(

*enpasar????????????.puul????..

  /an0 mem)a$

*ern+a$aan

  0onsignee

 

6666666666666666666666666666666666666666666

   Tan&a +angan &an

=ama 5engap

  $ignature and +ull)ame

Sa#si Sa#si

1itness   1itness

6666666666666666666666666666666666666

66666666666666666666666666666666666666666

 Tan&a +angan &an =ama 5engap Tan&a +angan &an

=ama 5engap

$ignature and +ull )ame   $ignature and +ull)ame