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HEALTH CERTIFICATE

No : ………………………

The undersigned of this, explains that :


Name :

Age :

Sex :

Address :

Occopation :

Based on examination that I do, the patient is in healthy condition. Then this letter is to be
used properly.

Note :
Blood Pressure :

Weight :

Height :

Colour Blindness :

Yogyakarta, March 16th , 2018


Doctor in charge

( dr. ……………………. )
SIP : ………………………………

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