Surat Keterangan Sehat Fisik Dan Mental
Surat Keterangan Sehat Fisik Dan Mental
Nama : ...................................................................................................
NPA IDI : ...................................................................................................
SIP : ...................................................................................................
Jabatan Kotawaringin Timur
: Dokter Pemeriksa Kesehatan di IDI Cabang ………………………....
105/IDI/KOTIM/IX/2016
Ketua IDI Cabang No………………….……………)
(Surat Keputusan…………………,
Nama : ...................................................................................................
Umur : ...................................................................................................
Alamat : ...................................................................................................
Spesialisasi : ...................................................................................................
Hasil Pemeriksaan :
Tempat : ...................................................................................................
Tanggal : ...................................................................................................
………………………………………………………
(Nama / tanda tangan)
NPA IDI ................................................ , SIP .....................................................................