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PUSKESMAS

”PRAMBON,SIDOARJO”
Jl.Raya Prambon No. 125, Prambon – Kab.Sidoarjo Tlp. (031) 8974735

SURAT KETERANGAN SAKIT


No. ................................/20......

Yang bertanda tangan di bawah ini Dr. / Kepala klinik Umum menerangkan :

Nama : .............................................................................................
Umur : .............................................................................................
Pekerjaan : .............................................................................................
Alamat : ..............................................................................................

Di karenakan sakit (.............) Perlu istirahat selama : ................................... hari,


Terhitung mulai tanggal : ...................................s/d.............................................

...........................................20.........