Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Enter the name of the patient in the designated field. This should be the full name as stated on official documents.
3. Provide the ID or passport number of the patient in the respective field. Ensure all details match the document.
4. Fill in the patient's date of birth and age in the specified format, using 'dd/mm/yyyy' for consistency.
5. Select the patient’s sex by indicating whether they are male or female.
6. Input the medical record number for reference, if applicable.
7. For the date of treatment, enter the start and end dates of the medical service, formatted as 'dd/mm/yyyy'.
8. Document the anamnesis or medical history by detailing any relevant health issues or symptoms the patient has experienced.
9. Indicate the date when the patient first experienced symptoms or complaints, using the 'dd/mm/yyyy' format.
10. Provide the date of the first consultation related to this disease, ensuring the date format is respected.
11. Fill in the referral doctor's name and address to establish the source of the consultation.
12. Detail the results of any physical examinations, lab tests, X-rays, or other diagnostic procedures.
13. State the final diagnosis or working diagnosis along with the corresponding ICD code.
14. Describe the therapy or treatment provided to the patient.
15. Clarify the medical indication for inpatient or outpatient care.
16. Indicate who requested the inpatient/outpatient service – either the doctor or the patient.
17. Choose the applicable categories related to the diagnosis, marking appropriate checkboxes.
18. If the patient has previously consulted or been hospitalized, provide details including dates and diagnoses.
19. Document any previous medical history and any factors related to the current illness or disorder.
20. If applicable, explain any surgical procedures attempted, including the type of surgery and the date it took place.
21. Conclude the form by affirming the accuracy of the inputted information. Include the doctor's name, specialization, address, and date of completion, alongside their signature and stamp.
22. Finally, review all completed sections for accuracy, then save changes, download, print, or share the form as needed.

Begin filling out the Indonesia Sequis Life Surat Keterangan Dokter/Attending Physician Statement online today to streamline your hospitalization claims.