RS. HIKMAH SEJAHTERA BELOPA RS.

HIKMAH SEJAHTERA BELOPA

Alamat: Jl.Topoka No. 22 B Kelurahan Tampumia Radda Alamat: Jl.Topoka No. 22 B Kelurahan Tampumia Radda
Kec. Belopa Kab. Luwu Email rshsbelopa@yahoo.com Kec. Belopa Kab. Luwu Email rshsbelopa@yahoo.com
Kepada Kepada
Yth. Bag. Radiologi Yth. Bag. Radiologi
Mohon Melakukan Pemeriksaan : Mohon Melakukan Pemeriksaan :

Foto Skull AP / Lat / Water’s Foto Tulang Belakang Foto Skull AP / Lat / Water’s Foto Tulang Belakang
Foto Thorax AP / PA / Lat Foto Cervical AP / Lat Foto Thorax AP / PA / Lat Foto Cervical AP / Lat
Foto Abdomen AP / BNO Polos Foto Thiracolumbal AP / Lat Foto Abdomen AP / BNO Polos Foto Thiracolumbal AP / Lat
Foto Lumbosacral AP / Lat Foto Lumbosacral AP / Lat
Foto BNO tiga posisi Foto Posisi Tambahan Foto BNO tiga posisi Foto Posisi Tambahan
Foto Pelvis Foto ............................... Foto Pelvis Foto ...............................
Foto extremitas suferior Foto Kontras Foto extremitas suferior Foto Kontras
Foto Clavikula Foto OMD Foto Clavikula Foto OMD
Foto Sholder Joint Foto BNO / IVP Foto Sholder Joint Foto BNO / IVP
Humerus AP Foto Colon In Loop Humerus AP Foto Colon In Loop
Elbow Joint AP / Lat Foto Uretro Cytografi Elbow Joint AP / Lat Foto Uretro Cytografi
Antebrachi AP / Lat Foto HSG Antebrachi AP / Lat Foto HSG
Wrist Joint AP / Lat USG Wrist Joint AP / Lat USG
Manus AP / Lat / Obliq USG Thyroid Manus AP / Lat / Obliq USG Thyroid
Foto Extermitas Inferior USG Mammae Foto Extermitas Inferior USG Mammae
Foto Hip Joint AP USG Abdomen Foto Hip Joint AP USG Abdomen
Foto Femur AP/ Lat USG ........................... Foto Femur AP/ Lat USG ...........................
Foto Knee Joint AP / Lat Foto Knee Joint AP / Lat
Foto Cruris AP / Lat Foto Cruris AP / Lat
Foto Ankel Joint AP / Lat Foto Ankel Joint AP / Lat
Foto Pedis AP / Obliq Foto Pedis AP / Obliq

No Rekam Medis : ....................................... Asal Ruangan : ................................... No Rekam Medis : ....................................... Asal Ruangan : ...................................
Nama Pasien : ........................................ Jaminan : .................................. Nama Pasien : ........................................ Jaminan : ..................................
Tgl/Bln/Thn Lahir : .............................. L / P Umur : ................................... Tgl/Bln/Thn Lahir : .............................. L / P Umur : ...................................
Klinis : ..................................................................................................... Klinis : .....................................................................................................
Belopa ........................... 20 Belopa ........................... 20
Dokter Pengirim Dokter Pengirim

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