DINAS KESEHATAN KABUPATEN BINTAN

UPT PUSKESMAS TELUK SEBONG

KLINIK PARIWISATA LAGOI

Bintan Resort Jl. Kota Kapur Lagoi 29155 Tlp.0770 - 692023

Medical Certificate
No:…………/KPL/2015
To whom it may concern :
This is to certify that :

Name : …………………………………………………………………………….
Age : …………………………………………………………………………….
Adress : …………………………………………………………………………….
Company : …………………………………………………………………………….

On date…………...carried out a medical examination of persons mentioned above with the results:
Need to take rest for…….(…..…) days from the date ………………to…………………..
With the diagnosis : ………………………………………………………………………..

Lagoi, 2015

Doctor In-Charge

DINAS KESEHATAN KABUPATEN BINTAN

UPT PUSKESMAS TELUK SEBONG

KLINIK PARIWISATA LAGOI

Bintan Resort Jl. Kota Kapur Lagoi 29155 Tlp.0770 - 692023

Medical Certificate
No:…………/KPL/2015
To whom it may concern :
This is to certify that :

Name : …………………………………………………………………………….
Age : …………………………………………………………………………….
Adress : …………………………………………………………………………….
Company : …………………………………………………………………………….

On date……………carried out a medical examination of persons mentioned above with the results:
Need to take rest for…….(…..…) days from the date ………………to…………………..
With the diagnosis : ………………………………………………………………………..

Lagoi, 2015

Doctor In-Charge