a Tokyo Institute of Technology Health Certificate (Part I) name Muhammad tacts —_Luth eansyah Date of Admission® * |0 we 0) 9.0 2. Date of Birth **1fyour arrival in Japan is late than the date of admission, vite the date you plan to enter the county. Part II. Student Immunization History Form (to be completed by physician) amunzation histor fr 1.MMR or ALL of b, must be complete, in adton to 2 and 3. Formed exemptions, please submit letersgne by «physician tating the medial candition that contrindicates vaccines. posed 81 25 1 902i [poe2 Lp wm 00 ww ww 0D WT, Japan Dose 1 08 1a FWA] L] Physician ciagnosed of history of eh MM DD oy 7 — w Dose 2 1 L Ly Hes porto postive (reactive) mune ter MUST SUBMIT A COPY OF LAB REPORT wm pow tad 3m Yoqon Taio Dose 1 021 1 AM 1 Physanseorosd ia of oate “DOW 4 imi 00 wv Dose 2 L t o ‘Has report of positive (reactive) immune titer a iw? ‘MUST SUBMIT A COPY OF LAB REPORT Bn Dagon sa Dose 1 of i Wi Physician-diagnosed of history of disease wt DD L 0D ‘Has report of postive (reactive) immune ter [MUST SUBMIT A COPY OF LAB REPORT po Dose t GB_1 25 1 WA |] Prysicianciagnosed of history of disease m0 1 ! mW Dose 2 Hes 00 of positive (reactive) immune ter me [MUST SUBMIT A COPY OF LAB REPORT Tn dopen ease Last booster (after age 11) Wp we woo wv. ‘certify that the above information is an accurate record of this student's immunizat NAME of Physician -Print Name_ de. 7 fovnmy Teac __ Signature Address_Ja¥erty __Uncovoa Email Ari Date:_os/v3(tt INDONESIA ence, * Wake na Thins 1018086 / Iona. Hots Toot, 1 28.04... ee, A 70EOG0n aRUMAH SAKIT e UNIVERSITAS INSSREHS | INDONESIA LETTER OF IMMUNIZATION ‘No, 250/KET-SKV/03-RSUU/ 2019 Explain that the person below : No. Medical Record : 00107069 Name : MUHAMMAD LUTHFANSYAH PRABOWO. Place/Date of Birth : Jakarta/ 19/10/1995 Address : JL, RAYA PS, MINGGU NO.8 RT. 002 RW. 001 KEL, PENJATEN BARUT PASER MINGGU. JAKARTA SEALTAN Blood pressure : 140/90 mmHg Weight : 116.5 Kg. Has been given immunization: 1.MMR 2. Varicella 3. Tetanus (On the date : 23/08/2021 Location : IM Deltoid Sinistra ‘Thus this statement was made to be used as required. Attending Physician dr, Tommy Toar Huberto Purnomo RSUI | Jl Prof. Dr. Bahder Djohan Kampus U! Depok | Telephone: 021 - 508 29 292| www.rs.ul