Surat Dokter - DR INDAH [PDF]

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UPEMERINTAH KABUPATEN BLITAR



PEMERINTAH KABUPATEN BLITAR



DINAS KESEHATAN DAERAH



DINAS KESEHATAN DAERAH



UPT PUSKESMAS NGLEGOK



UPT PUSKESMAS NGLEGOK



Telp. ( 0342 ) 561003



Telp. ( 0342 ) 561003



Nglegok, .......................



Nglegok, .......................



SURAT KETERANGAN DOKTER



SURAT KETERANGAN DOKTER



Nama



: .................................................................



Nama



: .................................................................



Umur/Tgl.Lahir



: .................................................................



Umur/Tgl.Lahir



: .................................................................



Pekerjaan



: .................................................................



Pekerjaan



: .................................................................



Alamat



: .................................................................



Alamat



: .................................................................



Sehat untuk : ................................................................. Diberi istirahat : .................................................................



Sehat untuk : ................................................................. Diberi istirahat : .................................................................



.................................................................



.................................................................



Mulai .......................................................



Mulai .......................................................



Catatan :



Dokter pemeriksa



1. Tekanan darah: 2. Tinggi Badan: 3. Berat Badan: 4. Buta Warna:



Mmhg cm. kg.



Catatan :



Dokter pemeriksa



1. Tekanan darah : Mmhg 2. Tinggi Badan: cm. 3. Berat Badan: kg. 4. Buta Warna:



dr. INDAH AMALIA NIP. 19810315 201502 2 002



dr. INDAH AMALIA NIP. 19810315 201502 2 002



PEMERINTAH KABUPATEN BLITAR



PEMERINTAH KABUPATEN BLITAR



DINAS KESEHATAN DAERAH



DINAS KESEHATAN DAERAH



UPT PUSKESMAS NGLEGOK



UPT PUSKESMAS NGLEGOK



Telp. ( 0342 ) 561003



Telp. ( 0342 ) 561003



Nglegok, .......................



SURAT KETERANGAN DOKTER



Nama



: .................................................................



Umur/Tgl.Lahir



: .................................................................



Pekerjaan



: .................................................................



Alamat



: .................................................................



Sehat untuk : ................................................................. Diberi istirahat : .................................................................



Nglegok, .......................



SURAT KETERANGAN DOKTER



Nama



: .................................................................



Umur/Tgl.Lahir



: .................................................................



Pekerjaan



: .................................................................



Alamat



: .................................................................



Sehat untuk : ................................................................. Diberi istirahat : .................................................................



.................................................................



.................................................................



Mulai .......................................................



Catatan :



Dokter pemeriksa



1. Tekanan darah : Mmhg 2. Tinggi Badan: cm. 3. Berat Badan: kg. 4. Buta Warna:



dr. INDAH AMALIA NIP. 19810315 201502 2 002



Mulai .......................................................



Catatan :



Dokter pemeriksa



1. Tekanan darah : Mmhg 2. Tinggi Badan: cm. 3. Berat Badan: kg. 4. Buta Warna:



dr. INDAH AMALIA NIP. 19810315 201502 2 002