PRO JUSTICIA

VISUM ET REPERTUM
No. ........./......../......../2018

---Saya yang bertanda tangan dibawah ini, dr. ..................................... Dokter Rumah Sakit Islam
Ar-Rasyid Palembang, menerangkan bahwa berdasarkan permintaan tertulis
dari ....................................................................................................................................................
.......
Tanggal : ......................................................... Nomor : ...................................................................
Tanggal : ......................................................... Pukul : ...................................................................
Bertempat di Rumah Sakit Islam Ar-Rasyid Palembang telah dilaksanakan pemeriksaan terhadap
korban dengan Nomor Registrasi ......./....... yang menurut surat tersebut adalah :
Nama : .........................................................................................................
Jenis Kelamin : .........................................................................................................
Tempat / Tanggal Lahir : .........................................................................................................
Kewarganegaraan : .........................................................................................................
Agama : .........................................................................................................
Pekerjaan : .........................................................................................................
Alamat : .........................................................................................................
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------------------------------------------HASIL PEMERIKSAAN-------------------------------------------
----------------------------------------Dari pemeriksaan didapatkan-----------------------------------------
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---Demikianlah Visum Et Repertum ini saya buat dengan sejujur-jujurnya dan menggunakan
ilmu yang sebaik-baiknya mengingat sumpah jabatan sesuai dengan KUHP.

Palembang, ..................................2018
Dokter Tersebut diatas

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