Mitra Medika Hospital

Sultan Abdurrahman Street Number.25

Pontianak,
West Borneo Indonesia
Telp. 0561-584888
www.mitramedikahealthcare.com

MEDICAL CERTIFICATE OF FITNESS TO FLY

No. 001/SK-LT/LT 8/RSMM/VI/2021

The undersigned below, explains that:

Patient name : LIU YONGHUA

Date of birth : June 7th 1974 (Male/Female*)
Address : Provinsi Street Tengar Kendawangan River Hamlet,
Ketapang West Borneo
Medical record number : 00-12-69-32

Treatment Date : June 02 th-04 th 2021

Additional medical information :

Based on the above, I here by declare that the patient is fit to travel by air.

Thank you for your attention.

Pontianak, June 4th 2021

Attending physician

(dr. Sugeng Krismawanto, Sp.OT )

Name and signature

*) Cross the unnecessary ones

Jalan Sultan Abdurrahman No. 25

Pontianak, Kalimantan Barat
Telp: 0561-584888 (hunting), Fax: 0561-576100
www.mitra medikahealthcare.com