RS.

ADI HUSADA
DINAS KESEHATAN KABUPATEN BEKASI
Office : Jl. Ki Hajar Dewantara Karang Bahagia, Bekasi

SURAT KETERANGAN SAKIT

Yang Bertanda Tangan Dibawah Ini, Menerangkan Bahwa :

Nama :........................................................................................................
Umur :.......................................................................................................
Jenis Kelamin :.......................................................................................................
Alamat :.......................................................................................................
.......................................................................................................

Perlu IstIrahat Selama :.......................(............................) Hari Dikarenakan Sakit.

Mulai Dari Tgl.......................................... Sampai Tgl.............................................
Mohon Yang Berkepentingan, Maklum Adanya.

Bekasi,..........................................20....

Dokter Pemeriksa,

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