Nama :……………………………………………………………………………………………………………….
Umur :……………………………………………………………………………………………………………….
Pekerjaan :……………………………………………………………………………………………………………….
Alamat :………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Pontianak…………….20….
Dokter Pemeriksa