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Jln. Gubernur Syarkawi KM. 3,9 Gambut - Kab.

Banjar
Telp. 0511 6730000-6730001-6730002,IGD (0511) 6730003 Fax. 0511 - 6730006
Website: www.sambanglihum.info, Email: rsjsambanglihum@yahoo.com

BLANGKO PERMINTAAN RADIOLOGI


Nama Pasien: _____________________
(L/P)
Umur
: _________________________

No RM
:
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Tanggal
: ___________________

Riwayat Klinis
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Permintaan Pemeriksaan
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Tanda Tangan dan Nama Terang
Dokter Penanggung Jawab

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HASIL PEMERIKSAAN RADIOLOGI


Nama Pasien: _____________________
(L/P)
Umur
: _________________________

No RM
:
___________________
Tanggal
: ___________________

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Tanda Tangan dan Nama Terang
Dokter Pemeriksa

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