Sie sind auf Seite 1von 2

Report Of Vaccination Record

Surat Keterangan Vaksin

The Undersigned Verifies The Authenticity Of The Following : / Yang Bertanda Tangan Di Bawah Ini
Menerangkan Dengan Sesungguhnya Bahwa :

Name / Nama : JESSIKA MATERA DOS SANTOS


Address / Alamat : Rio De Janeiro
Place & Date Of Birth / Tempat & Tgl. Lahir : Brazil, July, 22nd 1990
Sex / Jenis Kelamin : Female/perempuan

General Status / Keadaan Umum:


Blood Pressure / Tekanan Darah : 110/70 mmHg
Respiratory Rate / Laju Pernapasan : 20 Bpm
Pulse Rate / Denyut Nadi : 80 Bpm
Temperature / Suhu : 36.2 0C

Has Been Given The Vaccine At Klinik Utama Vidyan Medika at 16th June 2019 because of monkey
bites and need to get vaccinated on the D0, D3, D7, D14, and D28 according to the Verorab injection
schedule for post exposure prophylaxis / Memang Benar Telah Dilakukan Tindakan Vaksin Di Klinik
Utama Vidyan Medika Pada Tanggal 16 Juni 2019 akibat gigitan monyet dan injeksi diberikan pada
H0, H3, H7, H14, dan H28 sesuai jadwal injeksi Verorab untuk profilaksis pasca paparan.

Name Of Vaccine / Nama Vaksin : VERORAB


With The Vaccine Serial Number / Dengan Nomor Seri Vaksin : P1D051M
This Certificate Is Made To Be Used As Needed By The Person Named Above/
Demikian Surat Keterangan Ini Dibuat Untuk Dapat Dipergunakan Sebagaimanamestinya.

Gianyar, 16 June 2019


Klinik Utama Vidyan Medika

dr. Ni Wayan Enny Sukmawati, S.Ked


SIP:503/153.SIP.II/Diskes/2016
CERTIFICATE OF HEALTH REPORT

FROM: KLINIK UTAMA VIDYAN MEDIKA

The undersigned below explained truthfully that


Name : IDA AYU DIAN KUSUMA DEWI
Age : 27th years old
Occupation : Veterinarian
Address : Lingkungan Baler Bale Agung, Tegalcangkring, Mendoyo, Negara
Upon Request : For going overseas
In our curent examination shows that the person concern is in a good condition/health

This certificate is made to be used property


Weight : 58 kg
Height : 155 cm
Blood Pressure: 110/70 mmHg

Gianyar, June 7, 2019


DOCTOR

Dr. Ni Made Santhini P., S.Ked


S
SIP:503/101.SIP.I/Diskes/20187