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PEMERINTAH PROPINSI KALIMANTAN TIMUR RUMAH SAKIT UMUM DAERAH A.

WAHAB
SJAHRANIE
Jln. Dr Seotomo Telp. ( 0541 ) 738118 ( Hunting System ) Fax. 741793 SAMARINDA 75123

SURAT KETERANGAN SAKIT

NAMA :................................................................................................................................

UMUR : ...............................................................................................................................

ALAMAT : ...............................................................................................................................

DIAGNOSA : ...............................................................................................................................

ADVIS : ..................................................................... Dari tgl .........s/d.............................

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Samarinda,................,..............., .............

Dokter

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