PEMERINTAH KABUATEN TULUNGAGUNG

DINAS KESEHATAN

UPTD PUSKESMAS KARANGREJO

JL. Dahlia Nomor 13 Desa Karangrejo Telp. 0355 – 328810

SURAT KETERANGAN DOKTER

Yang bertanda tangan dibawah ini Dokter Pemeriksa Puskesmas..............................................

...............................................................Menerangkan bahwa :

Nama :.................................................................................................................

Jenis Kelamin :.................................................................................................................

Tanggal Lahir/ Umur :.................................................................................................................

Pekerjaan :.................................................................................................................

Pendidikan :.................................................................................................................

Alamat : ................................................................................................................

Tinggi Badan : ...........................Cm Berat Badan:....................................................Kg

Tensi : ............................Mm Hg

Pada pemeriksaan di dapatkan keadaan: sehat/ tidak sehat*

Surat keterangan ini dipergunakan untuk : ..................................................................................

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

Demikian Harap maklum

Dokter pemeriksa

*coret yang tidak perlu NIP/NRPTT