Scribd
Upload
104 views1 page

Medical Leave Certificate Template

Klinik Pratama is a clinic located on Jl. Raya Pegangsaan Dua KM 3.5 in Jakarta Utara. The document is a template for a medical certificate from Klinik Pratama that certifies a patient's diagnosis and need for rest for a specified number of days, with spaces to fill in the patient's name, gender, age, address, dates of required rest, diagnosis, and physician signature.

Uploaded by

Santy Mawis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
104 views1 page

Medical Leave Certificate Template

Klinik Pratama is a clinic located on Jl. Raya Pegangsaan Dua KM 3.5 in Jakarta Utara. The document is a template for a medical certificate from Klinik Pratama that certifies a patient's diagnosis and need for rest for a specified number of days, with spaces to fill in the patient's name, gender, age, address, dates of required rest, diagnosis, and physician signature.

Uploaded by

Santy Mawis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

KLINIK PRATAMA

“” KLINIK PRATAMA
Jl. Raya “BINA KASIH”
Jl. Raya Pegangsaan Dua KM 3.5
Jakarta Jakarta Utara14250
Telp. Telp. 4605050

Signed below explains that : Signed below explains that :


Name : …………………………………………………….................... Name : ……………………………………………………....................
Gender : Male / Female Gender : Male / Female
Age : ………… years Age : ………… years
Address : ……………………………………………………………….... Address : ………………………………………………………………....
…………………………………………………….................... ……………………………………………………....................

Based on result of the checks have been performed, the patient is in a State Based on result of the checks have been performed, the patient is in a State
of pain, so the need to rest during ……………… (........…) days, from the of pain, so the need to rest during ……………… (........…) days, from the
date of ………-………-20….. to ………-………-20….. date of ………-………-20….. to ………-………-20…..

Diagnosis : ………………………………………………………………… Diagnosis : …………………………………………………………………

Such certificate is granted to known and used as necessary. Such certificate is granted to known and used as necessary.

Jakarta, ………………. 20 …. Jakarta, ………………. 20 ….


The Physician Examiner, The Physician Examiner,

(dr. ……...…………………….) (dr. ……...…………………….)

You might also like