CERTIFICATE OF HEALTH

No. 07/SketMed/RSIAK/II/2014

I hereby authorized the release of the information as specified in the following :

Name :
Specialist : Paediatric
Certify that,
Name :
Sex :
Place and Date of Birth :
Address :

Was Admitted to Kurnia Hospital from July 8th to July 8th 2014
Indication for hospitalization : Observasion of febris and gastro acute
Diagnosis : Viral Infection
Febris Convulsion
Diare Acute
Therapy/Medical Treatment :
- Injection : Terfacef
Ondancentron
Mikasin
- Oral : Tempra
Narfoz
Lacto B
This report was made to whom it may concern.
Cilegon, February 26th 2014

R. Paulina M.MD
Pediatric