P E M E R I N TA H P R O V I N S I D A E R A H K H U S U S I B U K O TA J A K A RTA

D I N A S K E S E H ATA N
P U S AT K E S E H ATA N M A S YA R A K AT K E C A M ATA N K E B O N J E R U K
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J A K A R T A
K o d e P o s : 11 5 3 0

SURAT KETERANGAN BEROBAT

No. .................../PKM-KJ/............./20...
Yang bertanda tangan dibawah ini menerangkan bahwa :
Nama : ..........................................................................................................................................
Umur : ..........................................................................................................................................
Jenis Kelamin : ..........................................................................................................................................
Pekerjaan : ..........................................................................................................................................
Alamat : Jln.....................................................................................................................................
Menerangkan bahwa yang bersangkutan benar datang berobat di Puskesmas Kecamatan Kebon Jeruk
pada tanggal ................................................ Jam .......................................
Agar Surat Keterangan ini dapat dipergunakan seperlunya. Jakarta, ................................20.......
Yang memeriksa

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