Sistem Informasi Kesehatan Pelabuhan

Balai Kekarantinaan Kesehatan/Rumah Sakit

Klinik Utama CT-Klinik

No. Dokumen

Barcode Number

This is to certify that [Name]

Date Of Birth

Nationality

INDONESIA

National Identification Documents, If Applicable

Whose Signature Follows

Has on the date indicated been vaccinated or received prophylaxis againts: (name of disease or condition)

Vaccine or Prophy	Date	Signature and profesional status of supervising clinican	Manufacture and batch no. of vaccine or prophylaxis	Certificate valid until	Official stamp of the administering centre	Disease targeted	Date	Manufacture, brand name and batch no. of vaccine	Next Booster (date)	Official stamp and signature
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International Certificate Vaccination Or Prophylaxis