7/18/2019 Surat Sakit

K L I NI K U T A MA K L I NI K U T A MA K L I NI K U T A MA

Medika Antapani Medika Antapani Medika Antapani

IZIN NO : 445/5220-Dinkes/04-SIKU/VI/12 IZIN NO : 445/5220-Dinkes/04-SIKU/VI/12 IZIN NO : 445/5220-Dinkes/04-SIKU/VI/12
Jl. Purwakara N!." #el$. %022& '101((5 ) '200'"* Jl. Purwakara N!." #el$. %022& '101((5 ) '200'"* Jl. Purwakara N!." #el$. %022& '101((5 ) '200'"*
+na$ani ) ,anun +na$ani ) ,anun +na$ani ) ,anun

SURAT KETERANGAN SAKIT SURAT KETERANGAN SAKIT SURAT KETERANGAN SAKIT

an ,erana anan i awa ini !ker Klinik  an ,erana anan i awa ini !ker Klinik  an ,erana anan i awa ini !ker Klinik 
Ua3a eika +na$ani 3enerankan awa : Ua3a eika +na$ani 3enerankan awa : Ua3a eika +na$ani 3enerankan awa :

 Na3a : ....  Na3a : ....  Na3a : ....

U3ur :  #. 6 P U3ur :  #. 6 P U3ur :  #. 6 P
Peker7aan : ........ Peker7aan : ........ Peker7aan : ........

+la3a : .... +la3a : .... +la3a : ....

  .   .   .
Perlu 3ena$a isiraa karena saki sela3a ... Perlu 3ena$a isiraa karena saki sela3a ... Perlu 3ena$a isiraa karena saki sela3a ...
 ari 3ulai anal   ari 3ulai anal   ari 3ulai anal 
s/  s/  s/ 
De3ikian aar 8an erke$eninan 3en7ai De3ikian aar 8an erke$eninan 3en7ai De3ikian aar 8an erke$eninan 3en7ai
3aklu3 3aklu3 3aklu3

,anun  ,anun  ,anun 

D!ker Pe3eriksa D!ker Pe3eriksa D!ker Pe3eriksa

.. .. ..

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