Formulir Permintaan Pemeriksaan Laboratorium

Rumah Sakit Umum Daerah Bayung Lencir

Jl. Raya Palembang – Jambi KM. 200, Kel. Bayung Lencir,Kec. Bayung Lencir 30756

No. RM :....................................... Tanggal :......................

Nama Pasien :....................................... No. Telp :......................
Tanggal Lahir :....................................... L/P :......................
Alamat :.............................................................................................
Dokter Pengirim :.............................................................................................
Keterangan Klinis :.............................................................................................
Nama Ruang :.........................................../Umum/BPJS
Sampel di dapat :............................Sampel di periksa :..................................
Tanggal Pemeriksaan :........................................................

HEMATOLOGI URINALISA
KIMIA DARAH
 Hemoglobin  Warna Urin
 Lekosit  Glukosa Puasa
 Glukosa
 Hematokrit  Glukosa 2 Jam PP
 Bilirubin
 Trombosit  Glukosa Sewaktu
 Keton
 Eritrosit  Kolesterol Total
 LED  BJ
 SGOT
 Clotting Time  Blood
 SGPT
 Bleeding Time  pH
 Ureum
 Golongan Darah  Protein
 Hitung Jenis Lekosit  Kreatinin
 Urobilinigen
 MCV  Asam Urat
 Nitrit
 MCH  Tropinin-I
 Lekosit
 MCHC  T4
 TSH SEDIMEN URIN
SEROLOGI
 Thypoid Rapid Tes
 Hba1c
 Eritrosit/LPB
 HbsAg  HDL
 Lekosit/LPB
 HIV  Trigliserid  Epitel
ELEKTROLIT  Protein Total  Kristal
 Natrium  Albumin  Silinder
 Kalium
 Bilirubin Direct
 Clorida MIKROBIOLOGI
 Bilirubin Total
 Calsium
 Ph  TCM GENEXPERT


( * ) Puasa 8 – 12 Jam Bayung Lencir, / / 20...

Pengirim

( dr................................... )
Formulir Permintaan Pemeriksaan Laboratorium
Rumah Sakit Umum Daerah Bayung Lencir
Jl. Raya Palembang – Jambi KM. 200, Kel. Bayung Lencir,Kec. Bayung Lencir 30756

No. RM :....................................... Tanggal :......................

Nama Pasien :....................................... No. Telp :......................
Tanggal Lahir :....................................... L/P :......................
Alamat :.............................................................................................
Dokter Pengirim :.............................................................................................
Keterangan Klinis :.............................................................................................
Nama Ruang :.........................................../Umum/BPJS
Sampel di dapat :............................Sampel di periksa :..................................
Tanggal Pemeriksaan :........................................................

HEMATOLOGI URINALISA
KIMIA DARAH
 Hemoglobin  Warna Urin
 Lekosit  Glukosa Puasa
 Glukosa
 Hematokrit  Glukosa 2 Jam PP
 Bilirubin
 Trombosit  Glukosa Sewaktu
 Keton
 Eritrosit  Kolesterol Total
 LED  BJ
 SGOT
 Clotting Time  Blood
 SGPT
 Bleeding Time  pH
 Ureum
 Golongan Darah  Protein
 Hitung Jenis Lekosit  Kreatinin
 Urobilinigen
  Asam Urat
 Nitrit
  Tropinin-I
 Lekosit
 T4
 TSH SEDIMEN URIN
SEROLOGI
 Thypoid Rapid Tes  Hba1c
 Eritrosit/LPB
 HbsAg  HDL
 Lekosit/LPB
 HIV  Trigliserid  Epitel
 Protein Total  Kristal
 Albumin  Silinder
 Bilirubin Direct
 Bilirubin Total

( * ) Puasa 8 – 12 Jam Bayung Lencir, / / 20...

Pengirim

( dr................................... )