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				<text><![CDATA[FORMULIR PULANG ATAS PERMINTAAN SENDIRI]]></text>
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				<text><![CDATA[Dan saya tidak akan menuntut pihak RS Simpangan Depok atau siapapun juga akibat dari keputusan saya pulang atas permintaan sendiri.]]></text>
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				<text><![CDATA[Saya telah mendapatkan penjelasan tentang :                                                                                  1. Hak saya untuk menolak atau tidak melanjutkan pengobatan                                                                              2. Tentang konsekuensi dari keputusan saya                                                                                         3. Tentang tanggung jawab saya dengan keputusan tersebut                                                                                     4. Tersedia alternatif pelayanan dan pengobatan di RS Pilihan : ]]></text>
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