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				<text><![CDATA[Yang Menyatakan]]></text>
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				<text><![CDATA[Menyatakan bahwa benar saya/pasien menolak]]></text>
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				<text><![CDATA[sudah mendapatkan informasi mengenai resiko dari penolakan yang dilakukan yaitu :]]></text>
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				<text><![CDATA[dan tidak akan menuntut/menggugat pernyataaan ini dikemudian hari untuk alasan apapun.]]></text>
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				<text><![CDATA[Demikian peryataan ini saya buat dengan sebenar-benarnya. Atas perhatiannya saya ucapkan terima kasih. ]]></text>
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