PEMERINTAH KABUPATEN INDRAMAYU

UPTD PUSKESMAS DTP SUKAGUMIWANG

Jl. Raya Sukagumiwang Kecamatan Sukagumiwang Kode. Pos 4527 5
Email. pkmsukagumiwang0902@gmail.com

Projustitia

VISUM ET REPERTUM

Menerangkan dengan sesungguhnya bahwa:

Pada hari ................... tanggal .................. Jam ........... WIB, Telah memeriksa seorang korban bernama
.............................................. Jenis kelamin .......................... tempat tanggal lahir indramayu, umur ...............
tahun, pekerjaan ........................... agama Islam, bangsa Indonesia, alamat : ....................................
Kecamatan .............................. kab. .....................................

Hasil PEMERIKSAAN LUAR yang di dapat adalah sebagai berikut :

Kepala : ...........................................................................................................................................
Mata : ...........................................................................................................................................
Telinga : ...........................................................................................................................................
Mulut : ...........................................................................................................................................
Leher : ...........................................................................................................................................
Pipi : ...........................................................................................................................................
Dada : ...........................................................................................................................................
Perut : ...........................................................................................................................................
Pinggang : ...........................................................................................................................................
Anggota Gerak : Tanggan kanan : ...........................................................................................................
Tangan kiri : ...........................................................................................................
Kaki kanan : ...........................................................................................................
Kaki kiri : ...........................................................................................................

Kesimpulan: .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

Demikian Surat Keterangan ini saya buat dengan sejujurnya berdasarkan Sumpah dan Janji Dokter.

Sukagumiwang, ................................
Dokter Pemeriksa / Perawat

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