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Jumat, 06 April 2012

Surat Keterangan Lahir


KETERANGAN LAHIR
No : .........................................

Yang bertanda tangan di bawah ini, menerangkan bahwa
Pada hari ini .................................... , tanggal......................................., pukul................................telah lahir seorang bayi
Jenis Kelamin    : Laki-laki/Perempuan *
Jenis Kelahiran  : Tunggal/kembar 2/kembar 3/lainnya*
Kelahiran ke     :................................................
Berat lahir         :.........................................gram
Di rumah/rumah bidan/polindes/rumah bersalin/puskesmas/rumah sakit*............................................................................................................................................... alamat : ....................................................................................................................................................
Diberi nama :

.................................................................................................................................................................
 
 


Dari orang tua :
Nama ibu          :.............................................................................................Umur:......................tahun
Pekerjaan         :.......................................................................................................................................
KTP no.           : .....................................................................................................................................
Alamat             :.......................................................................................................................................
Kecamatan       : ......................................................................................................................................
Kab/kota           : ......................................................................................................................................
..................................tgl..............................
Penolong persalinan

**
............................................................
*lingkari yang sesuai
**Tanda tangan,nama lengkap,no induk pegawai,nama instansi






Rounded Rectangle: RUJUKAN
Tanggal/bulan/tahun  :.............../.................../...............Jam :........................................................
Dirujuk ke  :....................................................................................................................
Sebab dirujuk  :....................................................................................................................
Diagnosa sementara :....................................................................................................................
Tindakan sementara :....................................................................................................................
Yang Merujuk


.................................................


Rounded Rectangle: UMPAN BALIK RUJUKAN
Tanggal/bulan/tahun  :.............../.................../...............Jam :........................................................
Dirujuk ke  :....................................................................................................................
Sebab dirujuk  :....................................................................................................................
Diagnosa sementara :....................................................................................................................
Tindakan sementara :....................................................................................................................
Penerima rujukan


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