Persetujuan Tindakan Medis

(Informed Consent)

Klinik Utama Gleneagles

(GLENEAGLES CLINIC)


Saya yang bertandatangan di bawah ini
(I, who signed below)

Nama (Name)*


NIK/PASSPORT (Id/Passport Number)*

Alamat KTP (Address)*

* Diisi sesuai KTP (Based on ID)
Alamat Domisili (Residential address)

* Lewati Apabila Sesuai Dengan KTP
(No need to fill in if it matches with your ID)
Nomor Handphone (Phone Number)*

(Has received and understood the explanation, regarding)

* Pilih salah satu (Please select one)



(Therefore I agree to the examination.)
* Dapat memilih lebih dari satu (Could be selected more than one)
* Pilih salah satu (Please select one)
* Dapat memilih lebih dari satu (Could be selected more than one), abaikan jika bukan (ignore if not)
* Pilih salah satu (Please select one)
Jika iya, tuliskan kapan dan dimana
(Please confirm, and make a word)

* Diisi Negara tujuan perjalanan dan tanggal perjalanan (Based on country visited and travel months)
Vaksinasi Covid 19
(Covid-19 Vaccination)
*Tanggal Vaksin 1(1st Vaccination) *Tanggal Vaksin 2(2nd Vaccination) *Tanggal Vaksin 3(3rd Vaccination)
* Di isi sesuai tanggal dan Merk Vaksin (Based on Vaccination date and brand)

Hasil pemeriksaan dan informasi kesehatan lainnya bersifat rahasia. Hasil pemeriksaan hanya dapat diberikan kepada diri Anda sendiri, pihak yang berwenang (Dinas Kesehatan setempat, pihak berwajib Kepolisian dan instansi terkait lainnya sesuai dengan alur pelaporan hasil, perusahaan dan pihak asuransi sesuai perjanjian kerjasama/MOU).


- Hasil Pemeriksaan RT PCR (swab) selesai dalam kurun waktu 1 sampai 3x24 jam dari pelaksanaan swab



Selain kepada Dinas Kesehatan, pihak berwajib Kepolisian dan instansi lain sesuai alur pelaporan, hasil pemeriksaan dan informasi terkait lainnya dapat diketahui, dilaporkan dan dikirim kepada: (abaikan jika bukan)


Aspect of Confidentiality

The results of the examination and other health information are classified/confidential. The results of the examination are given only to the patient, the authorized parties (the Public Health Service, Police department and other relevant agencies in accordance with the results reporting flow, the company and the insurer according to the cooperation agreement/MOU).

Result

- The results of the Real Time PCR examination (swab) will be completed within 1-3x24 hours since the swab implementation.



In addition to the Public Health Service, Police department and other agencies according to the reporting flow, the results of examinations and other related information can be accessed, reported and sent to: (ignore if not)


Hasil di kirim melalui
(Result Will be send Via)

* Lewati Jika Nomor WA sama dengan Nomor Telpon
(No need to fill in if it matches with your Phone Number)
Asuransi (Insurance)
* Diisi sesuai dengan nama Asuransi pengirim (Please fill in according to the name of the sender insurance)
Perusahaan (Corporate)
* Diisi sesuai dengan nama Perusahaan pengirim (Please fill in according to the name of the sender corporate)
Dokter (Doctor)
* Diisi sesuai dengan nama Dokter pengirim (Please fill in according to the name of the sender doctor)
Lain-lain (Others)
* Diisi sesuai dengan nama pengirim (Please fill in according to the name of the sender name)

Demikian pernyataan persetujuan ini saya buat dengan penuh kesadaran dan tanpa paksaan dari pihak manapun dan bersedia mengikuti semua ketentuan serta alur pemeriksaan yang berlaku sesuai rekomendasi Kementrian Kesehatan Republik Indonesia.

Therefore, I have made this statement of agreement with full awareness and without coercion from any party and willing to follow all the terms and condition as well as the current examination flow according to the recommendation of the Ministry of Health of the Republic of Indonesia.
Surabaya *
* dd/MM/yyyy
Yang bertandatangan (Signature)*
Tanda Tangan (Sign Here)
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Sign Pad

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Petugas (Officer)
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Officer Sign

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KTP/KK/Passport (ID Card/Family Card/Passport)*

TSU-FR-PLY/02.11 Swab