............................................................. ............................................................. ............................................................. ............................................................. Bersama ini Kami Kirimkan Bersama ini Kami Kirimkan Nama : ................................................................................................... Nama : ................................................................................................... Umur : ................................................................................................... Umur : ................................................................................................... Alamat : ................................................................................................... Alamat : ................................................................................................... ................................................................................................... ................................................................................................... Diagnosa : ................................................................................................... Diagnosa : ................................................................................................... Mohon untuk pemeriksaan: Mohon untuk pemeriksaan: Golongan darah PITC Golongan darah PITC HB BTA HB BTA Protein urin Shipilis Protein urin Shipilis Reduksi urin HIV Reduksi urin HIV IMS HBSAG IMS HBSAG
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Bandung, ......................................... Bandung, ......................................... Salam Sejawat Salam Sejawat