PUSKESMAS KOTAKALER
KECAMATAN SUMEDANG UTARA
Jl.Sofyan Iskandar Telp.(0261) 203708 Sumedang
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Pada pemeriksaan kami tanggal : ................................................................................
Menerangkan :
BUTA WARNA / TIDAK BUTA WARNA
Keterangan ini diperlukan
untuk : ...................................................................................................................
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Sumedang, .................................................
Dokter Pemeriksa
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