POINS SQUARE MALL & APARTMENT

5TH FLOOR UNIT 7-8

JL. R. A. KARTINI NO. 1, LEBAK BULUS
JAKARTA SELATAN, INDONESIA 12440

No. : SK.02-PDMT/I/19

Medical Certificates for Spain VISA

To
Whom It May Concern
In Spain Embassy
JAKARTA

The undersigned Doctor in medicine DR. KARTIKA

License 18/B.15a/31.74.06.1002/-1.779.3/e/2018

Certifies that he/she has examined this day Mr./Mrs./Miss MIREIA MAAGDALIA

Nationality INDONESIA

Date and place of birth 1 NOVEMBER, 1997

Residing at JL. KEPODANG RAYA BLOK L-2 NO. 7

RENGAS, CIPUTAT TIMUR
TANGERANG SELATAN, 15412

This medical certificate attests that Mr. / Ms. MIREIA MAAGDALIA does not suffer from any illness that
would pose a threat to public health according to the International Health Regulations of 2005.

Este certificado médico acredita que la Sr./Srta. MIREIA MAAGDALIA no padece ninguna de las
enfermedades que pueden tener repercusiones de salud pública graves de conformidad con lo dispuesto en el
Reglamento Sanitario Internacional del 2005.

Signature Date :
Firma Fecha

DR. KARTIKA

Issued at PRIVÉ DENTAL AND MEDICAL TEAM at
JL. R. A. KARTINI NO. 1, 5TH FLOOR UNIT 7-8
LEBAK BULUS, CILANDAK
JAKARTA SELATAN, 12440
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