CONTOH SURAT KETERANGAN KELAHIRAN
No...../..../rumah sakit terkait/..../tahun
yang bertanda tangan dibawah ini:
Nama : .................................................................................
profesi : .................................................................................
Yang menerangkan bahwa kami telah ditolong / rawat bayi :
Nama : .................................................................................
Jenis kelamin : .................................................................................
Anak dari nyonya : .................................................................................
No KTP : .................................................................................
Alamat : ............................................................................................
Pekerjaan : .................................................................................
Dan Tuan : .................................................................................
No.KTP : .................................................................................
Alamat : .................................................................................
Pekerjaan : .................................................................................
Telp./HP : .................................................................................
No reg pasien Ibu : .................................................................................
Kelahiran ditolong pada : a. Hari ....................................................................
b. tanggal ...../ ...../........
c. Jam.
Adalah kelahiran yang ke : .................................................................................
Kembar : 1/2/3/4/5/ .....*)
Dengan panjang : ........ Cm
Berat Badan : .........Gram
Lingkar Kepala : .........Cm
Tindakan : ........(Kode/CD IX)
Kelainan Bawaan : ........(Kode/CD IX)
Jakarta, DD/ BB/ YYYY
ttd
an Dokter/Bidan
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