PEKANBARU
PUSKESMAS SIMPANG BARU KECAMATAN TAMPAN
Jl. Kamboja Panam, No. 10 Kecamatan Tampan Pekanbaru
Dokter :................................................................
Menerangankan bahwa
Nama :..................................................................
Umur :..................................................................
Pekerjaan :..................................................................
Alamat :..................................................................
Perlu beristirahat karena sakit selama........................................(..........) hari
Terhitung tanggal.......................................s/d..................................................
Harap yang berkepentingan maklum.
Pekanbaru,.........................201....
(......................................................)
Dokter :................................................................
Menerangankan bahwa
Nama :..................................................................
Umur :..................................................................
Pekerjaan :..................................................................
Alamat :..................................................................
Perlu beristirahat karena sakit selama........................................(..........) hari
Terhitung tanggal.......................................s/d..................................................
Harap yang berkepentingan maklum.
Pekanbaru,.........................201....
(......................................................)