SURAT KETERANGAN SAKIT

Yang bertanda tangan di bawah ini menerangkan bahwa :

Nama : ..................................................................................................................
Umur : ..................................................................................................................
Kelamin : ..................................................................................................................
Pekerjaan : ..................................................................................................................
Alamat : ..................................................................................................................
No KTP : ..................................................................................................................

Oleh karena sakit, maka memerlukan istirahat selama :..................................(....................) hari,

terhitung mulai tanggal....................................sampai dengan tanggal..........................................

Harap menjadi maklum.

Jakarta,...............................
Dokter yang memeriksa

(............................................)