PRAKTIK MANDIRI BIDAN

GHINA AGHISNA, AM. KEB

SIPB : 440/060/BD.2/4215/SUKET/DINKES/IV/2022
Kp. Cibojong Rt. 38/10 Desa. Pulosari Kec.Kalapanunggal Kab. Sukabumi
Tlp. 085723373328

SURAT KETERANGAN CUTI HAMIL

Yang bertanda tangan di bawah ini, Bidan Praktik Mandiri menerangkan bahwa :

Nama : .................................................................................................................................

Umur : .................................................................................................................................

Pekerjaan : .................................................................................................................................

Alamat : .................................................................................................................................

Sesuai Hasil Pemeriksaan Tgl ................................... Telah Hamil ± ..................................

Minggu ( .................. Bulan ), maka perlu mendapatkan izin cuti bersalin mulai
tanggal ................................................. s/d ......................................... ( selama .........................
bulan ).

Demikian untuk dapat dipergunakan seperlunya.

...................., ...........................20...

BIDAN

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