PEMERINTAH KABUPATEN CIREBON

DINAS KESEHATAN
UPT PUSKESMAS NANGGELA
Jl. RA. Kartini No. 59 Desa Nanggela Kec. Greged Kode Pos 45172
Email : pkmnanggela@gmail.com
Telp. (0231) 884 5 113
CIREBON

SURAT KETERANGAN HAMIL

Nama Pasien : .............................................................................................

Umur : ...........Tahun
Alamat : RT ........ RW..... Dusun / Blok ....................................
Desa ........................... Kec.Greged Kab.Cirebon

PASIEN INI DINYATAKAN HAMIL

Usia Kehamilan : ............................................................................................
HPHT : .............................. TP : ..........................................
Hasil Pemeriksaan : ............................................................................................
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Demikian surat keterangan ini di berikan untuk keterangan ..................................

Nanggela, ........................................20
Bidan Pemeriksa

YATI RUSMIATI, A.Md.Keb

NIP. 19700403 199203 2 004