Permintaan Lab.docx

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PEMERINTAH KABUPATEN BANYUMAS

DINAS KESEHATAN

PUSKESMAS I AJIBARANG Jl. Ajibarang-Purwokerto, Kec. Ajibarang Kab. Banyumas Telp. (0281) 571297 Kode Pos 53163, email : [email protected]

PERMINTAAN PEMERIKSAAN LABORATORIUM No.RM

: ________________________

Diagnosa

: ____________________

Nama Pasien

: ________________________

Dokter

: ____________________

Umur

:

Jenis Pemeriksaan*: INDIKASI MEDIS / APS

Alamat

: _________________

Ruang Pengirim*

Tanggal

: ________________________

Jenis Pembayaran : No. BPJS : ___________

L/P

Jam sampling :

: R.PU/R.PG/KIA/VK/IGD

Umum

HEMATOLOGI

 Darah Rutin



KIMIA KLINIK GDS

 Hb



GDP



HbsAg

 Trombosit



GD2JPP



Anti HIV

 Lekosit



Cholesterol



PP TEST

 Eritrosit



Asam urat



Sifilis

 Ht



Trigliserida

 Golda + rhesus



SGOT



SGPT



Ureum



Creatinine



LED



SEROLOGI Widal

BAKTERIOLOGI 

BTA

 

LAIN-LAIN ………………………… …………………………

*Centang parameter yang akan diperiksa

Keterangan : 

HASIL PEMERIKSAAN LAB. DIKIRIM KE DOKTER



HASIL PEMERIKSAAN LAB. DIAMBIL PASIEN Dokter Pengirim,

………………………

**Lingkari yang perlu

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