Menerangkan dengan sebenarnya bahwa : Nama : Ny. ....................................................................................................................................... Istri dari : Bpk. ..................................................................................................................................... Pekerjaan : ............................................................................................................................................. Alamat : ............................................................................................................................................. Telah datang berobat pada hari .............................tanggal................................. Jam ....................... WIB Dengan keluhan.......................................................................................................................................... .................................................................................................................................................................... Demikian untuk menjadikan periksa Pasuruan, ........................................