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PAVILIUN MERPATI PAV/FRM/011/27

RSUD Dr. SOEDONO MADIUN


Jl. Bali No. 36 Telp. (0351) 464325 Madiun 63116

SURAT KETERANGAN SAKIT

Yang bertanda tangan dibawah ini, menerangkan :


Nama : .................................................................................................................................................
Alamat : .................................................................................................................................................
Karena sakit perlu : ..................................................................................................................................................
Diberi cuti sakit : ............................................................ hari
Masuk Rawat Inap
Mulai tgl. ............................................................................... s/d tgl. .......................................................................
Keterangan : ..............................................................................................................................................................

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