<band height="802">
<rectangle>
<reportElement x="0" y="65" width="554" height="497"/>
</rectangle>
<textField>
<reportElement mode="Opaque" x="144" y="301" width="190" height="15"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$F{nm_pasien}]]></textFieldExpression>
</textField>
<textField>
<reportElement mode="Opaque" x="143" y="348" width="394" height="16"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="false"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$F{alamat}]]></textFieldExpression>
</textField>
<textField pattern="">
<reportElement mode="Opaque" x="460" y="317" width="52" height="18"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="false"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$F{jk}]]></textFieldExpression>
</textField>
<staticText>
<reportElement x="0" y="65" width="553" height="19"/>
<textElement textAlignment="Center" lineSpacing="Single">
<font fontName="Tahoma" size="14" isBold="true"/>
</textElement>
<text><![CDATA[PERSETUJUAN / PENOLAKAN TINDAKAN MEDIS]]></text>
</staticText>
<staticText>
<reportElement x="19" y="317" width="117" height="14"/>
<textElement textAlignment="Left" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[NOMOR RM]]></text>
</staticText>
<staticText>
<reportElement x="19" y="301" width="117" height="15"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[NAMA PASIEN]]></text>
</staticText>
<staticText>
<reportElement x="136" y="301" width="6" height="15"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[:]]></text>
</staticText>
<staticText>
<reportElement x="135" y="332" width="6" height="14"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[:]]></text>
</staticText>
<staticText>
<reportElement x="19" y="332" width="117" height="14"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[NO Identititas]]></text>
</staticText>
<staticText>
<reportElement x="453" y="317" width="6" height="18"/>
<textElement textAlignment="Left" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[:]]></text>
</staticText>
<staticText>
<reportElement mode="Opaque" x="380" y="317" width="72" height="18"/>
<textElement textAlignment="Left" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[Jenis Kelamin]]></text>
</staticText>
<staticText>
<reportElement x="135" y="347" width="6" height="16"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[:]]></text>
</staticText>
<staticText>
<reportElement x="19" y="347" width="117" height="16"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[Alamat]]></text>
</staticText>
<staticText>
<reportElement x="4" y="547" width="289" height="13"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma"/>
</textElement>
<text><![CDATA[*) Coret yang tidak sesuai]]></text>
</staticText>
<image scaleImage="FillFrame" onErrorType="Blank">
<reportElement x="4" y="3" width="56" height="52"/>
<imageExpression class="java.io.InputStream"><![CDATA[$P{logo}]]></imageExpression>
</image>
<textField>
<reportElement x="64" y="41" width="319" height="14"/>
<textElement lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["E-mail : "+$P{emailrs}]]></textFieldExpression>
</textField>
<textField>
<reportElement x="64" y="30" width="319" height="14"/>
<textElement lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$P{kontakrs}]]></textFieldExpression>
</textField>
<textField>
<reportElement x="64" y="3" width="319" height="17"/>
<textElement lineSpacing="Single">
<font fontName="Tahoma" size="14"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$P{namars}]]></textFieldExpression>
</textField>
<textField>
<reportElement x="64" y="19" width="319" height="14"/>
<textElement lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$P{alamatrs}+", "+$P{kotars}+", "+$P{propinsirs}]]></textFieldExpression>
</textField>
<componentElement>
<reportElement x="398" y="6" width="123" height="49"/>
<jr:barbecue xmlns:jr="http://jasperreports.sourceforge.net/jasperreports/components" xsi:schemaLocation="http://jasperreports.sourceforge.net/jasperreports/components http://jasperreports.sourceforge.net/xsd/components.xsd" type="Code128" drawText="false" checksumRequired="false" barHeight="85">
<jr:codeExpression><![CDATA[$F{no_rkm_medis}]]></jr:codeExpression>
</jr:barbecue>
</componentElement>
<textField pattern="">
<reportElement mode="Opaque" x="460" y="298" width="52" height="17"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="false"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$F{umur}]]></textFieldExpression>
</textField>
<staticText>
<reportElement x="453" y="299" width="6" height="17"/>
<textElement textAlignment="Left" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[:]]></text>
</staticText>
<staticText>
<reportElement mode="Opaque" x="380" y="299" width="65" height="17"/>
<textElement textAlignment="Left" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[Umur]]></text>
</staticText>
<break>
<reportElement x="0" y="781" width="100" height="1"/>
</break>
<textField>
<reportElement x="9" y="90" width="546" height="20"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Saya yang bertandatangan dibawah ini :"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="19" y="114" width="95" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Nama"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="19" y="134" width="95" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Umur"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="286" y="134" width="97" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Jenis Kelamin"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="19" y="155" width="95" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Alamat Lengkap"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="19" y="177" width="95" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Bukti Diri"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="114" y="114" width="441" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[": .............................................................................................................."]]></textFieldExpression>
</textField>
<textField>
<reportElement x="114" y="134" width="138" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[": .....................Tahun"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="383" y="134" width="138" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[": Laki-Laki / Perempuan"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="114" y="155" width="426" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[": .............................................................................................................."]]></textFieldExpression>
</textField>
<rectangle>
<reportElement x="331" y="184" width="10" height="13"/>
</rectangle>
<rectangle>
<reportElement x="388" y="184" width="10" height="13"/>
</rectangle>
<rectangle>
<reportElement x="436" y="184" width="10" height="13"/>
</rectangle>
<textField>
<reportElement x="9" y="216" width="512" height="20"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Bersama ini menyatakan dengan sesungguhnya telah memberikan PERSETUJUAN / PENOLAKAN untuk dilakukan :"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="34" y="237" width="82" height="20"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Rawat Inap"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="144" y="237" width="108" height="20"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Pemasangan Infus"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="298" y="238" width="89" height="20"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Injeksi"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="406" y="239" width="146" height="20"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10" isBold="true"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Pengambilan darah"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="34" y="257" width="441" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[".............................................................................................................."]]></textFieldExpression>
</textField>
<textField>
<reportElement x="9" y="279" width="479" height="20"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Terhadap Diri Saya Sendiri / Istri / Suami / Anak / Ayah / Ibu / Keluarga Saya* Dengan :"]]></textFieldExpression>
</textField>
<staticText>
<reportElement x="136" y="316" width="6" height="15"/>
<textElement textAlignment="Left" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<text><![CDATA[:]]></text>
</staticText>
<textField>
<reportElement mode="Opaque" x="143" y="333" width="240" height="14"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="false"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$F{no_ktp}]]></textFieldExpression>
</textField>
<textField>
<reportElement x="9" y="364" width="361" height="14"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Saya juga menyatakan dengan sesungguhnya dan tanpa paksaan bahwa saya :"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="15" y="381" width="536" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["1. Telah diberikan informasi dan penjelasan serta peringatan akan bahaya, serta kemungkinan yang dapat timbul apabila"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="28" y="393" width="264" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["dilakukan tindakan seperti diatas."]]></textFieldExpression>
</textField>
<textField>
<reportElement x="15" y="406" width="276" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["2. Telah Paham sepenuhnya informasi yang diberikan dokter."]]></textFieldExpression>
</textField>
<textField>
<reportElement x="15" y="418" width="319" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["3. Mau menerima segala resiko yang terjadi akibat tindakan tersebut."]]></textFieldExpression>
</textField>
<textField>
<reportElement x="374" y="437" width="41" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[$P{kotars}+","]]></textFieldExpression>
</textField>
<textField pattern="dd MMMMM yyyy">
<reportElement x="417" y="437" width="100" height="13"/>
<textElement lineSpacing="Single"/>
<textFieldExpression class="java.util.Date"><![CDATA[new java.util.Date()]]></textFieldExpression>
</textField>
<textField>
<reportElement x="2" y="456" width="114" height="13"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Dokter"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="445" y="452" width="107" height="26"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Yang membuat pernyataan"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="147" y="456" width="113" height="13"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Saksi Dari Klinik"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="291" y="456" width="123" height="13"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Saksi Dari Pasien"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="4" y="527" width="114" height="13"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["(..................................)"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="147" y="527" width="114" height="13"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["(..................................)"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="291" y="527" width="114" height="13"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["(..................................)"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="437" y="527" width="114" height="13"/>
<textElement textAlignment="Center" verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["(..................................)"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="7" y="586" width="111" height="31"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["SETUJU MENDAPATKAN TINDAKAN :"]]></textFieldExpression>
</textField>
<line>
<reportElement x="1" y="566" width="554" height="1"/>
</line>
<textField>
<reportElement x="64" y="609" width="473" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA[".................................................................................... (............................................ )"]]></textFieldExpression>
</textField>
<line>
<reportElement x="0" y="630" width="555" height="1"/>
</line>
<textField>
<reportElement x="9" y="570" width="210" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["Tanggal : / /"]]></textFieldExpression>
</textField>
<rectangle>
<reportElement x="19" y="240" width="10" height="13"/>
</rectangle>
<rectangle>
<reportElement x="130" y="240" width="10" height="13"/>
</rectangle>
<rectangle>
<reportElement x="284" y="241" width="10" height="13"/>
</rectangle>
<rectangle>
<reportElement x="393" y="241" width="10" height="13"/>
</rectangle>
<rectangle>
<reportElement x="19" y="261" width="10" height="13"/>
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<textField>
<reportElement x="115" y="177" width="198" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
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<textFieldExpression class="java.lang.String"><![CDATA[": ......................................................."]]></textFieldExpression>
</textField>
<textField>
<reportElement x="344" y="177" width="26" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
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<textFieldExpression class="java.lang.String"><![CDATA["KTP"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="403" y="177" width="26" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
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<textFieldExpression class="java.lang.String"><![CDATA["SIM"]]></textFieldExpression>
</textField>
<textField>
<reportElement x="449" y="178" width="91" height="20"/>
<textElement verticalAlignment="Bottom" lineSpacing="Single">
<font fontName="Tahoma" size="11"/>
</textElement>
<textFieldExpression class="java.lang.String"><![CDATA["............................."]]></textFieldExpression>
</textField>
<textField>
<reportElement x="9" y="638" width="210" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
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<textFieldExpression class="java.lang.String"><![CDATA["Tanggal : / /"]]></textFieldExpression>
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<textField>
<reportElement x="9" y="654" width="111" height="31"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
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<textFieldExpression class="java.lang.String"><![CDATA["SETUJU MENDAPATKAN TINDAKAN :"]]></textFieldExpression>
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<textField>
<reportElement x="64" y="676" width="473" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
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<textFieldExpression class="java.lang.String"><![CDATA[".................................................................................... (............................................ )"]]></textFieldExpression>
</textField>
<line>
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</line>
<textField>
<reportElement x="9" y="704" width="210" height="13"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
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<textFieldExpression class="java.lang.String"><![CDATA["Tanggal : / /"]]></textFieldExpression>
</textField>
<textField>
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<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
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<textFieldExpression class="java.lang.String"><![CDATA["SETUJU MENDAPATKAN TINDAKAN :"]]></textFieldExpression>
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<textField>
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<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="10"/>
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<textFieldExpression class="java.lang.String"><![CDATA[".................................................................................... (............................................ )"]]></textFieldExpression>
</textField>
<line>
<reportElement x="0" y="760" width="554" height="1"/>
</line>
<textField>
<reportElement mode="Opaque" x="144" y="317" width="200" height="15"/>
<textElement verticalAlignment="Middle" lineSpacing="Single">
<font fontName="Tahoma" size="11" isBold="true"/>
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<textFieldExpression class="java.lang.String"><![CDATA[$F{no_rkm_medis}]]></textFieldExpression>
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<line>
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</line>
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