Keterangan Sakit

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Keterangan Sakit

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dr.

ELGA
1l. Pepaya raya Belimbing Padang

SURAT KETERANGAN SAKIT
Yang bertanda tangan di bawah ini menerangkan bahwa :
Nama : ................
Tgl. Lahir : ................
Pekerjaan : ................
Alamat : ................
................
................

Pada pemeriksaan Jasmani saat ini dalam Keadaan sakit,
sehingga perlu beristirahat selama ... hari, dari tanggal ...
sampai tanggal .......

Diagnosa,

Padang, ........
Dokter pemeriksa

(............)

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