WAKTU : WAKTU : WAKTU : WAKTU :

No. Jaminan Kesehatan : No. Jaminan Kesehatan : No. Jaminan Kesehatan : No. Jaminan Kesehatan :

UNIT RAWAT JALAN UNIT RAWAT JALAN UNIT RAWAT JALAN UNIT RAWAT JALAN
UMUM/GIGI/KIA/TB UMUM/GIGI/KIA/TB UMUM/GIGI/KIA/TB UMUM/GIGI/KIA/TB
MOHON PEMERIKSAAN LAB: MOHON PEMERIKSAAN LAB: MOHON PEMERIKSAAN LAB: MOHON PEMERIKSAAN LAB:
NO. RM : ................................................. NO. RM : ................................................. NO. RM : ................................................. NO. RM : .................................................
NAMA : ................................................. NAMA : ................................................. NAMA : ................................................. NAMA : .................................................
UMUR : ................................................. UMUR : ................................................. UMUR : ................................................. UMUR : .................................................
ALAMAT : ................................................. ALAMAT : ................................................. ALAMAT : ................................................. ALAMAT : .................................................

Gula Darah Puasa Widal Gula Darah Puasa Widal Gula Darah Puasa Widal Gula Darah Puasa Widal
Gula Darah 2 PP DL Gula Darah 2 PP DL Gula Darah 2 PP DL Gula Darah 2 PP DL
Gula Darah Acak Hb Gula Darah Acak Hb Gula Darah Acak Hb Gula Darah Acak Hb
Cholesterol Leukosit Cholesterol Leukosit Cholesterol Leukosit Cholesterol Leukosit
HDL – Cholesterol Hematokrit HDL – Cholesterol Hematokrit HDL – Cholesterol Hematokrit HDL – Cholesterol Hematokrit
LDL – Cholesterol Trombosit LDL – Cholesterol Trombosit LDL – Cholesterol Trombosit LDL – Cholesterol Trombosit
Trigliserida LED Trigliserida LED Trigliserida LED Trigliserida LED
Total Protein BT Total Protein BT Total Protein BT Total Protein BT
Albumin CT Albumin CT Albumin CT Albumin CT
Globulin Gol. Darah Globulin Gol. Darah Globulin Gol. Darah Globulin Gol. Darah
Bilirubin Total UL Bilirubin Total UL Bilirubin Total UL Bilirubin Total UL
Bilirubin Direx HCG Bilirubin Direx HCG Bilirubin Direx HCG Bilirubin Direx HCG
SGOT Protein Urine SGOT Protein Urine SGOT Protein Urine SGOT Protein Urine
SGPT HIV SGPT HIV SGPT HIV SGPT HIV
Uric Acid ……………………….. Uric Acid ……………………….. Uric Acid ……………………….. Uric Acid ………………………..
Creatinin ……………………….. Creatinin ……………………….. Creatinin ……………………….. Creatinin ………………………..
Hbs. Ag ……………………….. Hbs. Ag ……………………….. Hbs. Ag ……………………….. Hbs. Ag ………………………..
Hbs. Ab ……………………….. Hbs. Ab ……………………….. Hbs. Ab ……………………….. Hbs. Ab ………………………..
BUN ……………………….. BUN ……………………….. BUN ……………………….. BUN ………………………..
BTA : S …………… ……………………….. BTA : S …………… ……………………….. BTA : S …………… ……………………….. BTA : S …………… ………………………..
: P …………… : P …………… : P …………… : P ……………
: S …………… : S …………… : S …………… : S ……………

Sopaah,.................................2020 Sopaah,.................................2020 Sopaah,.................................2020 Sopaah,.................................2020

BTR BTR BTR BTR

(……………………………………………) (……………………………………………) (……………………………………………) (……………………………………………)

KET : KET : KET : KET :