Scribd
Upload
57 views1 page

Form Penilaian

This document is a laboratory test request form containing the patient's information such as name, date of birth, doctor, date and time of sample collection. It lists several hematology, chemistry, immunoserology, parasitology and other tests that can be requested along with spaces for the doctor's diagnosis and signature. The form is bilingual with one side in Indonesian and the other in English for universal use.

Uploaded by

DIANA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
57 views1 page

Form Penilaian

This document is a laboratory test request form containing the patient's information such as name, date of birth, doctor, date and time of sample collection. It lists several hematology, chemistry, immunoserology, parasitology and other tests that can be requested along with spaces for the doctor's diagnosis and signature. The form is bilingual with one side in Indonesian and the other in English for universal use.

Uploaded by

DIANA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

Penanggung jawab: dr. Yuni Kusuma Hartatik, M. sc, Sp. PK Penanggung jawab: dr. Yuni Kusuma Hartatik, M.

gung jawab: dr. Yuni Kusuma Hartatik, M. sc, Sp. PK


Nama : ……………………….. Dokter Pengirim :……………………….. Nama : ……………………….. Dokter Pengirim :………………………..
Tgl. Lahir: ……………………….. Penjamin :Umum/BPJS Tgl. Lahir: ……………………….. Penjamin :Umum/BPJS
Tanggal : …………………………. No. Rekam Medis:……………………….. Tanggal : …………………………. No. Rekam Medis:………………………..
Ruangan :………………………….. Jenis Sampel: Darah EDTA /Serum /Urine Ruangan :………………………….. Jenis Sampel: Darah EDTA /Serum /Urine
Jam Pengambilan Sampel : ……… Jam Penerimaan Sampel :………. Jam Pengambilan Sampel : ……… Jam Penerimaan Sampel :……….
Jam Selesai Pemeriksaan :………. Diganosa/klinis:…………………………………. Jam Selesai Pemeriksaan :………. Diganosa/klinis:………………………………….

FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM

HEMATOLOGI KIMIA DARAH URINALISA HEMATOLOGI KIMIA DARAH URINALISA


Darah lengkap Glukosa Puasa Urine Lengkap Darah lengkap Glukosa Puasa Urine Lengkap
Hemoglobin Glukosa 2 Jam PP Protein Urine Hemoglobin Glukosa 2 Jam PP Protein Urine
Lekosit Glukosa Sewaktu Reduksi Urine Lekosit Glukosa Sewaktu Reduksi Urine
Hitung Jenis Lekosit Cholesterol Total Keton Urine Hitung Jenis Lekosit Cholesterol Total Keton Urine
Hematokrit LDL Sedimen Urine Hematokrit LDL Sedimen Urine
Eritrosit HDL Tes Kehamilan Eritrosit HDL Tes Kehamilan
Trombosit Trigliserida Trombosit Trigliserida
Nilai Index Eritrosit Ureum IMUNOSEROLOGI Nilai Index Eritrosit Ureum IMUNOSEROLOGI
Led Creatinin Widal Led Creatinin Widal
Masa Perdarahan Asam Urat TUBEX Masa Perdarahan Asam Urat TUBEX
Masa Pembekuan SGOT HBsAg Masa Pembekuan SGOT HBsAg
Gambaran Darah Tepi SGPT Dengue IgG/IgM Gambaran Darah Tepi SGPT Dengue IgG/IgM
Cross Match Bilirubin Total ICT Malaria Cross Match Bilirubin Total ICT Malaria
Golongan Darah Bilirubin Direct IgM Anti Salmonella Golongan Darah Bilirubin Direct IgM Anti Salmonella
Bilirubin Indirect Bilirubin Indirect

PARASITOLOGI PEMERIKSAAN LAIN PARASITOLOGI PEMERIKSAAN LAIN


Malaria Mikroskopis ………………… Bandar Lampung,……….20.. Malaria Mikroskopis ………………… Bandar Lampung,……….20..
Feaces Lengkap ………………… Dokter Pengirim Feaces Lengkap ………………… Dokter Pengirim
Filaria ………………… Filaria …………………

( ) ( )

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy