Anda di halaman 1dari 5

Bidan Eri Lestari S.Tr.

Keb

Desa Bodelor Blok Tumaritis Kecamatan Plumbon Kabupaten Cirebon

Surat Keterangan Lahir

Yang bertanda tangan di bawah ini Eri Lestari S.Tr.Keb Bidan Praktik Swasta di Bodelor – Plumbon

Menerangkan telah lahir seorang anak Laki – laki / Perempuan pada hari .......................................

Tanggal ....................................... dengan BBL ............. PB............. di Desa Bodelor – Plumbon,

Di beri nama ......................................................................................................................................

dari seorang ibu :

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

Umur : .............................................................................................

No KTP : .............................................................................................

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

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

Dari Suami

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

Umur : .............................................................................................

No KTP : .............................................................................................

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

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

Bodelor,..................................

Eri Lestari S.Tr.Keb


Bidan ERI LESTARI S.Tr.Keb

Desa Bodelor Blok Tumaritis Kecamatan Plumbon Kabupaten Cirebon

Surat Keterangan Lahir

Yang bertanda tangan di bawah ini Eri Lestari S.Tr.Keb Bidan Praktik Swasta di Bodelor – Plumbon,
Menerangkan telah lahir seorang anak Laki – laki / Perempuan pada hari .......................................

Tanggal ....................................... dengan BBL ............. PB............. di Desa Bodelor – Plumbon,

Di beri nama ......................................................................................................................................

dari seorang ibu :

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

Umur : .............................................................................................

No KTP : .............................................................................................

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

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

Dari Suami

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

Umur : .............................................................................................

No KTP : .............................................................................................

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

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

Bodelor,..................................

Eri Lestari S.Tr.Keb

NIP.197212201992032004
Bidan Eri Lestari S.Tr.Keb

Desa Bodelor Blok Tumaritis Kecamatan Plumbon Kabupaten Cirebon

SURAT RUJUKAN

Kepada

Yth. .............................................

Di

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

Dengan ini saya kirimkan pasien :

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

Umur : .......................................................................................................

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

Dengan Keluhan :

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

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

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

Hasil Pemeriksaan :

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

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

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

Diagnosa / Analisa :

...............................................................................................................................................................
Bidan Eri Lestari S.Tr.Keb

Desa Bodelor Blok Tumaritis Kecamatan Plumbon Kabupaten Cirebon

SURAT RUJUKAN

Kepada

Yth.
.............................................

Di

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

Dengan ini saya kirimkan pasien :

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

Umur : .......................................................................................................

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

Dengan Keluhan :

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

Hasil Pemeriksaan :

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

Diagnosa / Analisa :

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

Mohon pemeriksaan / tindakan lebih lanjut.

Terimakasih

Bodelor,..................................
Eri Lestari
S.Tr.Keb

NIP.197212201992032004