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RUMAH SAKIT GRIYA HUSADA MADIUN

UNIT RADIOLOGI
Jl. Mayjen Pandjaitan No. 22 Madiun, Telp / Fax (0351) 472802 , 472803

Baru
:
Ulangan :

FORMULIR PERMINTAAN PEMERIKSAAN RADIOLOGI

Catatan :

Nama

: ................................................................................................

Jenis Kel.& Umur

: ........................................................./ ..............................Thn

Alamat

: ................................................................................................

Foto lama harap


dibawa

Poliklinik / Ruangan : ................................................. No. RM : ...............................

..................................................................................................................................

Pemakaian Film
Ukuran Baik Rusak
18 X 24
24 X 30
30 X 35
35 X 35
35 X 43
USG
CT Scan

Keterangan Klinis

: ................................................................................................

..................................................................................................................................
Permintaan Foto rontgen / USG / CT Scan / Thorax ................................................
..................................................................................................................................
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Madiun, ........, ............................., 20......
Dokter,
( .................................................)

Gunting Disini

RS. GRIYA HUSADA MADIUN


NO. RM

Nama

Jenis Kel.

: L/P
:

Jenis Foto

Tgl .
Umur :

RS. GRIYA HUSADA MADIUN


UNIT RADIOLOGI
Jl. Mayjend Pandjaitan No. 22 Telp./ Fax. (0351)

Thn

472802/472803

FORMULIR HASIL PEMERIKSAAN


RADIOLOGI

Dokter,

( ......................................................)

UNIT RADIOLOGI
Jl. Mayjen Pandjaitan No. 22 Telp./ Fax. (0351)
472802 / 472803

FORMULIR HASIL PEMERIKSAAN


RADIOLOGI

Dokter,
( ...)