PEMERINTAH KABUPATEN TULANG BAWANG

DINAS KESEHATAN
BLUD PUSKESMAS PADUAN RAJAWALI
KECAMATAN MERAKSA AJI
Alamat : Jln. Abdoel Moeloek Gg. Durian Paduan Rajawali , Kec. Meraksa Aji, Kab. Tulang Bawang
Telp 082376654026, Kode Pos 34681, Email : pkm.paduanrajawali89@gmail.com

VISUM ET REPERTUM
NOMOR : 440/ / PKM-PR / VET/ ......../2022
Pro Justisia
Pendahuluan : Berdasarkan Surat Permintaan Penyidik Polsek Gedung Aji
Nama : ................................................................
Pangkat : ................................................................
Nrp : ................................................................
Nomor Surat : ................................................................

Maka pada hari ........................Tanggal,.... Bulan …………Tahun 20...... Jam..............Wib

Bertempat Di Puskesmas Paduan Rajawali kami dengan :
Nama : ................................................................
Jabatan : .................................................................
Pangkat : ..................................................................

Telah melakukan pemeriksaan terhadap :

Nama : ..................................................................
Umur : .....................Tahun
Jenis Kelamin : Perempuan / laki-laki
Alamat : ...................................................................................................
Isi Keadaan umum : ................................................................
Kesadaran : ................................................................
Tekanan Darah : ............./ .........mmhg, Pernapasan : ......./mnt,
Denyut nadi......./ mnt
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Kesimpulan : ........................................................................................................................
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Penutup :
Demikian visum et Repertum ini di buat berdasarkan Sumpah Jabatan Dokter

Paduan Rajawali, ....... ........................ 2022

Yang Menerangkan
dokter Puskesmas

dr. A N T O N I
NIP. 1986 0726 2014 10.1.001