Medical Certificate Certificado Médico

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First found May 22, 2018

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Medical Certificate
A
Surat keteragan
Prescribing doctor – resep dokter:
______________
_______________
_____________
_____________
(name / nama belakang)
(first name(s) / nama depan)
(phone / telephone)
(fax / fax)
_______________________________________________________________
(address / alamat)
B
C
Patient – Pasien:
______________________________
___________________________
(name / nama belakang)
(first name(s) / nama depan)
_____________________________________________
(place of birth / tempat lahir)
________________________________________
(date of birth / tanggal lahir)
______________________________
____________________________
(no. of passport / nomer pasport)
(sex: male / female - jenis kelamin: laki-laki\perempuan)
______________________________
____________________________
(nationality / warga negara)
(duration of travel in days / barapa lama bepergian)
__________________
______________________
(date of arrival / tanggal kedatangan)
(date of departure / tanggal keberangkatan)
Prescribed drug – menerangkan obat - obatan:
_____________________________
_________________________
(trade name / nama produk obat))
(daily dose (mg) / penggunaan perhari (mg))
________________________
_________________________
(international name of actice substance /
nama dalam bahasa nasional)
(dosage form: liquid / tablets /
takaran dalam bentuk cairan / tablet)
____________________
_____________________
(concentration of active substance /
nama terkandung dalam isi pokok/yang terkandung
(duration of prescription in days /
ketentuan lama penggunan atau masa berlaku)
______________________
(total quantity of active substance (mg) /
Jumlah penggunaan yang di butuhkan (mg)
The medication the patient carries has been legally prescribed for medical treatment purposes. Confiscating/not taking
the medication leads to a life-threatening condition.
pengobatan terhadap pasien telah sesuai menurut ketentuan medis yang mana bertujuan sesuai dengan
pengobatan. Jika tanpa pengobatan ini akan mengancam hidup atau mengancam keadaan penderita.
__________________________________________
__________________
(Signature and stamp of the physician / tanda tangan, meterai atau cap dokter)
(Date / tanggal)

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