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RUMAH SAKIT UMUM `AISYIYAH

ST. KHADIJAH KABUPATEN PINRANG


Jl. A.Abdullah No. 1-3 Tlp (0421) 921406 – 924990 Kab. Pinrang Sulawesi Selatan
e-mail: rsa.stkhadijah@yahoo.com

SURAT KETERANGAN KELAYAKAN VAKSINASI COVID – 19

Saya yang bertanda tangan dibawah ini :


Nama : .....................................................................................................................
Menerangkan bahwa
Nama : .....................................................................................................................
Tanggal Lahir : .....................................................................................................................
Diagnosa : .....................................................................................................................
: .....................................................................................................................
Setelah dilakukan pengkajian yang komprehensif, Layak / Tunda / Tidak Layak * mendapatkan
vaksinasi COVID – 19.
Demikian surat keterangan ini dibuat untuk dipergunakan sebagaimana mestinya

Catatan :
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

Pinrang, .......................................
Dokter

dr. MARZUKI JAMAIN, Sp. PD

 Coret yang tidak Perlu

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