FORMULIR PEMERIKSAAN PATOLOGI ANATOMI

Kepada
Yth. Dokter Sp. Patologi anatomi
RS.
Di -
Tempat

Mohon dilakukan pemeriksaan ...................................................................................

Pada pasien
Nama :
Jenis kelamin :
Umur :
Alamat :

Keterangan bahan yang dikirim:

Lokasi jaringan : ..................................................................................................
Keterangan Klinik : ...................................................................................................
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....................................................................................................
Diagnosa klinik : ....................................................................................................
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Hasil pemeriksaan radiologi / lainnya:...........................................................................
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Rumbia Tengah, 2019

Dokter Pengirim

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