UNIT RADIOLOGI
Jl. Mayjen Pandjaitan No. 22 Madiun, Telp / Fax (0351) 472802 , 472803
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Nama
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Pemakaian Film
Ukuran Baik Rusak
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24 X 30
30 X 35
35 X 35
35 X 43
USG
CT Scan
Keterangan Klinis
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Permintaan Foto rontgen / USG / CT Scan / Thorax ................................................
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Madiun, ........, ............................., 20......
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UNIT RADIOLOGI
Jl. Mayjen Pandjaitan No. 22 Telp./ Fax. (0351)
472802 / 472803
Dokter,
( ...)