KLINIK RAWAT INAB YAYASAN ISMADANA

Jl. H.M.OtehRebudin No.161 Rt.01 PasarIlirMuaraduaKab.OKU Selatan

HP.0811 7265 456.Email :klinikismadana@gmail.com

SURAT KETERANGAN MEDIS PASIEN

Saya yang bertanda tangan di bawah ini menerangkan bahwa pasien :

Nama :

No BPJS :

Diagnosa :

Dengan kondisi pasien saat ini

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Demikian disampaikan surat keterangan ini dibuat dengan sebenar-benarnya hanya untuk
kepentingan medis.

Muaradua,
Dokter Yang Merawat

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