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FORMULIR PERMOHONAN
PEMERIKSAAN BAKTERIOLOGI TB

 Nama Unit Yankes  PU!"#!$%!

PU!"#!$%! D&'&DU& D&'&DU& No. (e)* (e)* Pasien .......................
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 Nama Dokter
Dokter Pengirim  ........................................
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(er+ga -Pasien
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/enis "e)amin  'aki  'aki Perem*an
%)amat 'engka*  ...............................................................
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/enis (er+ga - Pasien (
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Proinsi  !)awesi Utara ( 3I ( 5&

 N&. I+entitas
I+entitas !e+iaan !esai
!esai +atar ter+ga
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(angga)
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(an+a (anga
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Alaa! Pe!eri"aan #
Diagnosa ( Diagnosis ( 5&
Pemantaan "ema:an Pengoatan  )an "e
Pemeriksaan U)ang Pas;a Pengoatan ( 5&  )an "e
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(- ( 5& <askes  ................................................................
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 No. 5eg (
( - ( 5& "a-"ota  ................................................................
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Jeni Dan Ju!la$ Pe!eri"aan L%"ai Ana&%!i

(%  ................................................................. Par
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(est e*at 'P% 'okasi  ...................................
iakan ? ........................................................... '%n&%$ U(i
U:i "e*ekaan 'ini 1  ....................................... Dahak 
U:i "e*ekaan 'ini 2  ....................................... 'ain@a  .......................

!e;ara isa) Daha tam*ak  eri (an+a A *a+a "otak 

 Nanah 'en+ir
'en+ir er;ak Darah
Darah %ir 'ir  Ikhwan, ……………………2017
Dokter Pengirim
!ewakt-*agi

!ewakt-*agi
Dr. Jaqueline Olivia Lapian
!ewakt-*agi NIP.
NIP. 19870107 201704 2 006
 HASIL PEMERIKSAAN BAKTERIOLOGI TB
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(an+a (angan Pemeriksa,
Dokter P/ Pemeriksaan 'aoratorim

NI N9OMAN SURITI
……………………………………………….
 NIP.198C1210 200701 2 001

B Diisi sesai +engan ko+e hr sesai i+entitas se+ian wakt *engami)an +ahak 
BB eri tan+a rm*t A *a+a hasi) *emeriksaan - tingkat *ositi @ang sesai
BBB Isi +engan /m)ah (% - k)oni @ang +itemkan
BBBB Untk ko)om IN3 +an 5I< +iisi 5  5esisten, !  !ensiti 
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