PEMERINTAH KABUPATEN DEMAK

DINAS KESEHATAN
PUSKESMAS GUNTUR II
JL. Raya Pamongan Genuk, Desa Pamongan kecamatan Guntur Demak 59565

SURAT KETERANGAN DOKTER

NO. /PKM GUNTUR II/ /

Yang bertanda tangan dibawah ini,dokter Puskesmas Guntur 2 menerangkan bahwa :

Nama :......................................................................................................................
Umur :.................Tahun, Jenis Kelamin..................................................................
Pekerjaan :......................................................................................................................
Alamat :......................................................................................................................
Keperluan :......................................................................................................................
Keterengan : Sehat / Tidak Sehat
Telinga :.........................................
Mata :.........................................
Tinggi Badan :.........................................cm
Berat Badan :.........................................Kg
Tekanan Darah:.........................................mmHg
Lain-lain :.........................................