............................2020
Nama : .............................................................( L /
P)
Umur : ...............Tahun
Pekerjaan : .........................................................................
Alamat : .........................................................................
.........................................................................
Diagnosa : .........................................................................
.........................................................................
Perlu istirahat selama ......................... Hari, karena sakit,
terhitung mulai tanggal ........................... s/d .........................
Apabila diperlukan keterangan selanjutnya mengenai
kesehatannya, sudilah kiranya menghubungi kami.
Tertanda