Klinik

Jln. Letjen Pandjaitan No. 13 Jember

Telp. 0331 – 485136

SURAT KETERANGAN SAKIT

Yang bertanda tangan dibawah ini menerangkan bahwa :

Nama : ...............................................................................................................
Umur : ...............................................................................................................
Pekerjaan : ...............................................................................................................
Alamat : ...............................................................................................................

Perlu beristirahat karena sakit selama, ............................. ( ......................................... ) hari,

Terhitung tanggal .......................................................... s/d ...................................................
Harap yang berkepentingan maklum.

Jember, ......................................

Dokter Pemeriksa,

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