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KLINIK RAWAT INAP PRATAMA

PKU MUHAMMADIYAH JATIPURO KARANGANYAR


Alamat : Jl. Jatipuro-Jatiyoso KM.01 Jatipuro Kab. Karanganyar  : 57784
Telep. 0851 0306 8061, Email : klinikpku.jatipuro@gmail.com

SURAT KETERANGAN MONDOK


No : ..........................................................

Yang bertandatangan dibawah ini menerangkan bahwa:


Nama : ................................................................................................................
Jenis Kelamin : ................................................................................................................
Umur : ................................................................................................................
Pekerjaan : ................................................................................................................
Alamat : .................................................................................................................

Karena menderita sakit perlu mondok selama .....................(..................................................) Hari


Terhitung mulai tanggal ................................................ s/d tanggal.................................................
Harap yang berkepentingan maklum.

Karanganyar, .............................20.......
Dokter Klinik Rawat Inap Pratama
PKU Muhammadiyah Jatipuro,

(..............................................)
SIP :

KLINIK RAWAT INAP PRATAMA


PKU MUHAMMADIYAH JATIPURO KARANGANYAR
Alamat : Jl. Jatipuro-Jatiyoso KM.01 Jatipuro Kab. Karanganyar  : 57784
Telep. 0851 0306 8061, Email : klinikpku.jatipuro@gmail.com

SURAT KETERANGAN MONDOK


No : ...........................................................

Yang bertandatangan dibawah ini menerangkan bahwa:


Nama : ................................................................................................................
Jenis Kelamin : ................................................................................................................
Umur : ................................................................................................................
Pekerjaan : ................................................................................................................
Alamat : .................................................................................................................

Karena menderita sakit perlu mondok selama .....................(..................................................) Hari


Terhitung mulai tanggal ................................................ s/d tanggal.................................................
Harap yang berkepentingan maklum.

Karanganyar, .............................20.......

Dokter Klinik Rawat Inap Pratama


PKU Muhammadiyah Jatipuro,

(..............................................)
SIP :

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