(KOP SURAT RS/ KLINIK/ LABORATORIUM YANG MEMERIKSA)

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MEDICAL CERTIFICATE
No:________________

I, the Undersigned Doctor in Medicine, have examined:

Name :
Place, date of birth :
Age :
Nationality :
Height/ weight :
Blood type :

I have found that Mr. / Ms. / Mrs. _______________________________________________

is in healthy condition after through:

1. The basic medical check-up : ……………………………………………………………*)

2. Diagnosis of HIV/ Aids : ……………………………………………………………*)
3. Tuberculosis test : ……………………………………………………………*)
4. Hepatitis test : ……………………………………………………………*)

_________________________, 2018

_________________________

______________
*)
Copy of laboratory medical check-up result is attached