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Klinik Jln. Letjen Pandjaitan No. 13 Jember Telp. 0331 – 485136
SURAT KETERANGAN SAKIT Yang bertanda tangan dibawah ini menerangkan bahwa : Nama Umur Pekerjaan Alamat
: ............................................................................................................... : ............................................................................................................... : ............................................................................................................... : ...............................................................................................................
Perlu beristirahat karena sakit selama, ............................. ( ......................................... ) hari, Terhitung tanggal .......................................................... s/d ................................................... Harap yang berkepentingan maklum. Jember, ...................................... Dokter Pemeriksa,
( ............................................... )