-
- Pasien/keluarga/ penanggung jawab
....................................... {{ .Responsible_Name }}
- |
-
- Pemberi Informasi
....................................... {{ .InformationGivenBy_Name }}
- |
-
- Saksi I
....................................... {{ .Witness1_Name }}
- |
-
- Saksi II
....................................... {{ .Witness2_Name }}
- |
-
+
+ |
+
+ Pasien/keluarga/ penanggung jawab
+
+
+
+ .......................................
+
+
+
+ {{ .Responsible_Name }}
+
+ |
+
+
+
+ Pemberi Informasi
+
+
+
+ .......................................
+
+
+
+ {{ .InformationGivenBy_Name }}
+
+ |
+
+
+
+ Saksi I
+
+
+
+ .......................................
+
+
+
+ {{ .Witness1_Name }}
+
+ |
+
+
+
+ Saksi II
+
+
+
+ .......................................
+
+
+
+ {{ .Witness2_Name }}
+
+ |
+
+
+
+