PEMERINTAH KABUPATEN INDRAMAYU PEMERINTAH KABUPATEN INDRAMAYU

DINAS KESEHATAN DINAS KESEHATAN

UPTD PUSKESMAS KROYA UPTD PUSKESMAS KROYA
Jl. PU Kroya No.50 Kecamatan Kroya Jl. PU Kroya No.50 Kecamatan Kroya

PERMINTAAN PEMERIKSAAN PERMINTAAN PEMERIKSAAN

Nama : .................................................... Nama : ....................................................

Umur : .................................................... Umur : ....................................................
Alamat : .................................................... Alamat : ....................................................
unit Pengirim : .................................................... unit Pengirim : ....................................................
No. BPJS : .................................................... No. BPJS : ....................................................

HEMATOLOGI URINE KIMIA DARAH HEMATOLOGI URINE KIMIA DARAH

Hemoglobin Protein Glukosa Hemoglobin Protein Glukosa
Gol. Darah Glukosa Asam Urat Gol. Darah Glukosa Asam Urat
PH Cholestrerol PH Cholestrerol
VCT / HIV VCT / HIV

MIKROBIOLOGI MIKROBIOLOGI
Preparat BTA Preparat BTA
Sputum SPS Sputum SPS

Kroya, ..........................2020 Kroya, ..........................2020

Poli ................................. Poli .................................

....................................... .......................................
NIP. ............................... NIP. ...............................
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KROYA
Jl. PU Kroya No.50 Kecamatan Kroya

PERMINTAAN PEMERIKSAAN

Nama : ....................................................
Umur : ....................................................
Alamat : ....................................................
unit Pengirim : ....................................................
No. BPJS : ....................................................

HEMATOLOGI URINE KIMIA DARAH

Hemoglobin Protein Glukosa
Gol. Darah Glukosa Asam Urat
PH Cholestrerol
VCT / HIV

MIKROBIOLOGI
Preparat BTA
Sputum SPS

Kroya, ..........................2020
Poli .................................

.......................................
NIP. ...............................
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KROYA
Jl. PU Kroya No.50 Kecamatan Kroya

PERMINTAAN PEMERIKSAAN

Nama : ....................................................
Umur : ....................................................
Alamat : ....................................................
unit Pengirim : ....................................................
No. BPJS : ....................................................

HEMATOLOGI URINE KIMIA DARAH

Hemoglobin Protein Glukosa
Gol. Darah Glukosa Asam Urat
PH Cholestrerol
VCT / HIV

MIKROBIOLOGI
Preparat BTA
Sputum SPS

Kroya, ..........................2020
Poli .................................

.......................................
NIP. ...............................
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KROYA
Jl. PU Kroya No.50 Kecamatan Kroya

PERMINTAAN PEMERIKSAAN

Nama : ....................................................
Umur : ....................................................
Alamat : ....................................................
unit Pengirim : ....................................................
No. BPJS : ....................................................

HEMATOLOGI URINE KIMIA DARAH

Hemoglobin Protein Glukosa
Gol. Darah Glukosa Asam Urat
PH Cholestrerol
VCT / HIV

MIKROBIOLOGI
Preparat BTA
Sputum SPS

Kroya, ..........................2020
Poli .................................

.......................................
NIP. ...............................