1.

Format VeR klinik

INSTALASI GAWAT DARURAT RS MAHAPATIH GADJAH MADA

Jalan Mapahit no 01 Yogyakarta Telp 0274 101020
----------------------------------------------------------------------------------------------------------------------------
PRO JUSTITIA
VISUM ET REPERTUM
No. / TUM/VER/VIII/2008

Yang bertanda tangan di bawah ini, ........................... dokter spesialis forensik pada RS ...........................,
atas permintaan dari kepolisian sektor........................ dengan suratnya nomor....................tertanggal..........
...................maka dengan ini menerangkan bahwa pada tanggal....................... pukul...................bertempat
di RS.... ........................, telah melakukan pemeriksaan korban dengan nomor registrasi............................,
yang menurut surat tersebut adalah :
Nama :..............................................................................................................................................
Umur :..............................................................................................................................................
Jenis Kelamin : ............................................................................................................................................
Warga Negara : ............................................................................................................................................
Pekerjaan :..............................................................................................................................................
Agama :..............................................................................................................................................
Alamat :..............................................................................................................................................

HASIL PEMERIKSAAN :
1. Korban datang dalam keadaan .....................................
..............................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
2.Pada korban ditemukan -----------------------------------------------------------------------------------------------
a. .............................................................................................................................................................
.............................................................................................................................................................
...........................................................................................................................................................
b. .............................................................................................................................................................
.............................................................................................................................................................
...........................................................................................................................................................
................................................................................................................................................................
3.Pemeriksaan..penunjang/lab..........................................................................................................................
.......................................................................................................................................................................
4.Terhadap korban dilakukan .........................................................................................................................
........................................................................................................................................................................
5.Korban dipulangkan/dirawat .......................................................................................................................
........................................................................................................................................................................

KESIMPULAN : -------------------------------------------------------------------------------------------
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..............................................................................................................................................................

PENUTUP :----------------------------------------------------------------------------------------------------------------
Demikianlah visum et repertum ini dibuat dengan sebenarnya dengan menggunakan keilmuan yang
sebaik-baiknya, mengingat sumpah sesuai dengan Kitab Undang-Undang Hukum Acara Pidana.

Yogyakarta,............................................(tanggal bukan tahun )

Dokter pemeriksa,