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MEDICAL CERTIFICATE

This is to certify that :

Name :

Age :

Address :

Have been examined with diagnose :

And being given the following treatment :

For days

Remarks:

Payment for Medical Expenses

Doctors fee : Rp.

Medicine : Rp.

Others : Rp.

Total : Rp.

Bali,

Doctors in charge,

( Signature & Name in block letters )

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