Permintaan Pemeriksaan Patologi Anatomi & Sitologi

Nama/ usia : .........................................................

Jenis Kelamin : .........................................................
Alamat : .........................................................
RS/ Poli : ..........................................................
No. Reg : .......................................................... VIP-KL.I-II-III-POLI:.............................................

Lokasi Organ : .......................................................... Biopsi/Operasi/Kerokan .......................................

Diagnosa Klinik : .......................................................... Sputum/Urine/Smear/Cairan .................................
............................................................ Bahan Fiksatif .......................................................
Keterangan Klinik ............................................................ ................................................................................

Dr pengirim : .................................................

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

Alamat : .................................................

No. Pemeriksaan :
Riwayat Histopatologi / Sitologi Sebelumnya :

No Lab : Tgl.
Tgl. Haid Terakhir
Operasi .........................................
Tanggal terima :
......................
.............................................................
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Dokter yang Mengirim