WIRATAMA KACAMATA

Jl. Masaran, Kebayanan 3, Jirapan, Masaran, Sragen 57282

Telp. 0852-5792-1140

SURAT KETERANGAN
Berdasarkan pemeriksaan mata yang dilakukan pada .............................................., menerangkan bahwa :
Nama : ..................................................................................................................
Alamat : ..................................................................................................................
Telah melakukan pemeriksaan mata dengan hasil sebagai berikut:

SPH CYL ADD AXIS PD

Mata Kanan (R)
Mata Kiri (L)
Keterangan :
.............................................................................................................................................................................
.............................................................................................................................................................................
Sragen, .........................................

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

WIRATAMA KACAMATA
Jl. Masaran, Kebayanan 3, Jirapan, Masaran, Sragen 57282
Telp. 0852-5792-1140

SURAT KETERANGAN
Berdasarkan pemeriksaan mata yang dilakukan pada .............................................., menerangkan bahwa :
Nama : ..................................................................................................................
Alamat : ..................................................................................................................
Telah melakukan pemeriksaan mata dengan hasil sebagai berikut:

SPH CYL ADD AXIS PD

Mata Kanan (R)
Mata Kiri (L)
Keterangan :
.............................................................................................................................................................................
.............................................................................................................................................................................
Sragen, .........................................

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