PEMERINTAH KABUPATEN MOJOKERTO

DINAS KESEHATAN
UPT PUSKESMAS TROWULAN
Jalan Raya Trowulan No.179 Mojokerto, Kode Pos 61362 Jawa Timur
Email : pkm.trowulan@gmail.com Telp. 0857-3221-5650

Nomor :
Perihal : Hasil VER atas Korban Bernama ....................................

VISUM ET REPERTUM
VER/ 09 / Res / 20.... / Polsek

Yang bertanda tangan di bawah ini ............................................................

menerangkan bahwa atas permintaan tertulis
dari ...................................................................................
Tanggal .......................................................,...........................................................................
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............. Yang ditandatangani
oleh ........................................................................................................ Maka pada
tanggal ..................................................................... pukul .................................... Waktu
Indonesia Bagian Barat di UPT Puskesmas Trowulan Kecamatan Trowulan Kabupaten
Mojokerto Telah Dilakukan Pemeriksaan luar VISUM ET REPERTUM yang menurut
surat tersebut atas nama :
Nama :.............................................................................................
Jenis Kelamin :.............................................................................................
Tempat/ Tgl Lahir :.............................................................................................
Pekerjaan :.............................................................................................
Kewarganegaraan :.............................................................................................
Agama :.............................................................................................
Alamat :.............................................................................................
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HASIL PEMERIKSAAN
PEMERIKSAAN
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KESIMPULAN
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Mojokerto, ............................................
UPT Puskesmas Trowulan

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NIP. ..................................