SURAT KETERANGAN
Nama : ....................................................................
Umur :......................................................................
Pekerjaan :.....................................................................
Alamat :.....................................................................
............................................................................................
Berdasarkan hasil pemeriksaan yang telah dilakukan, pasien
tersebut dalam keadaan sakit, sehingga perlu beristirahat
selama...........hari, dari tanggal....................S/D
tanggal........................................................................
Bangkalan,.............................
(.......................................................)