SURAT KETERANGAN SEHAT

No. :

Yang bertanda tangan dibawah ini, Dokter Puskesmas Buniwagi, Menerangkan bahwa:
Nama : ............................................................................................L/P
Umur : .................................................................................................
Pekerjaan : .................................................................................................
Alamat : .................................................................................................
Berat Badan : .................................................................................................
Tinggi Badan : .................................................................................................
Telah diperiksa kesehatan pada hari ....................................... tanggal .................................... dalam
keadaan SEHAT/TIDAK SEHAT untuk memenuhi persyaratan................................................................................
.................................................................................................................................................................................

Harap yang berkepentingan maklum

Buniwangi,......................................
Yang diperiksa Dokter pemeriksa,

(...........................................) (.............................................)
NIP.