UNIVERSITAS GADJAH MADA

RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAH MADA

Jl. Kabupaten (Lingkar Utara), Kronggahan, Trihanggo, Yogyakarta 55291
Telp : (0274) 4530404, 4530505

MEDICAL CERTIFICATE
Number : ………………………………………..

By signing below, I, as part of Universitas Gadjah Mada Hospital Team, hereby

declared that:
I. PATIENT’S IDENTITY
Name : …………………………………………………
Medical Record Number : …………………………………………………
Place and Date of Birth : …………………………………………………
Address : …………………………………………………

II. INFORMATION ON PATIENT’S CONDITION

1. Patient was registered at ……………… of Universitas Gadjah Mada
Hospital, at ………………...
2. Physical Examination Result :
Height : …………. cm
Weight : …………. kg
Temperature : …………. ºC
3. Reverse Transcription Polymerase Chain Reaction (RT-PCR)
Nasopharyngeal Swabs :
SWAB I RT-PCR (……………………) : …………
SWAB II RT-PCR (……………………) : …………
Result : ……………………………………………….
Whose signature is given above, is found physically fit.

Yogyakarta,
On behalf of The Medical Team

(……………….…………………)