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Unit : .........................

FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM


UPT PUSKESMAS JERUKLEGI 1

NAMA : .................................................................
UMUR : .................. JENIS KELAMIN : ................
ALAMAT : .................................................................

HEMATOLOGI KIMIA KLINIK URINE


 Hemoglobin  Glukosa Puasa  Protein
 Eritosit  Glukosa 2 JPP  Glukosa
 Leukosit  Glukosa Sewaktu  Test Kehamilan
 Trombosit  Cholesterol  Urine Rutin
 LED  Asam Urat Lainnya :
 Golongan Darah SEROLOGI 1 .........................
 Malaria  Widal 2 .........................
SPUTUM  HIV
 Sputum BTA  NS1

POLI : .........................
FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM
UPT PUSKESMAS JERUKLEGI 1

NAMA : .................................................................
UMUR : .................. JENIS KELAMIN : ................
ALAMAT : .................................................................

HEMATOLOGI KIMIA KLINIK URINE


 Hemoglobin  Glukosa Puasa  Protein
 Eritosit  Glukosa 2 JPP  Glukosa
 Leukosit  Glukosa Sewaktu  Test Kehamilan
 Trombosit  Cholesterol  Urine Rutin
 LED  Asam Urat Lainnya :
 Golongan Darah SEROLOGI 1 .........................
 Malaria  Widal 2 .........................
SPUTUM  HIV
 Sputum BTA  NS1

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