KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

DIREKTORAT JENDERAL PELAYANAN KESEHATAN

RSUP DR SARDJITO YOGYAKARTA
Jl. Kesehatan No. 1 Sekip Yogyakarta Telepon +62-274-587333 Faksimile +62-274-565639
Pos-El :admin@sardjitohospital.co.id Laman :http://www.sardjito.co.id

SURAT KETERANGAN ISTIRAHAT SAKIT

MEDICAL CERTIFICATE FOR LEAVE

NO. SR.05.02/D.XI.1.5.1/342/2023

Yang bertanda tangan dibawah ini, Tim Medis RSUP Dr Sardjito Yogyakarta menerangkan bahwa:
I, the undersigned, as a medical team of Dr. Sardjito General Hospital Yogyakarta, hereby certify, that:

No. RM. / MR No. : 01166388

Nama / Tgl. Lahir / Patient Name / Date of : JUMIYEM / 12-06-1967
Birth
Jenis Kelamin / Sex : PEREMPUAN / FEMALE
Alamat / Address : Pelem RT.002 RW.003 Watangrejo Pracimantoro Kab. Wonogiri Jawa
Tengah

Karena sakit/dirawat di Rumah Sakit ini, perlu diberi istirahat selama (1) hari,
terhitung mulai tanggal 29-05-2023 s/d 29-05-2023.
Because of his/her illness need treatment in this hospital/should consider a period absence for (1) days,
starting from 29-05-2023 until 29-05-2023.

Yogyakarta, 29 Mei 2023

Poliklinik Penyakit Dalam
A.n. Tim Medis
U/b Medical Team

dr. FAHMI INDRARTI Sp.PD. KGEH.

(SIP: 446/8201/625/XII-23)
Tembusan :
Filled Copies
1. Instalasi Catatan Medis (Ditempel dalam berkas Rekam Medis)
1. Medical Record Divison (to be embedded in the medical record)

Tgl. cetak : 29-05-2023 12:54:10 REV-I-1-16-05 RM.3.01.425

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