DINAS KESEHATAN KABUPATEN BULUKUMBA DINAS KESEHATAN KABUPATEN BULUKUMBA

PUSKESMAS KAJANG PUSKESMAS KAJANG

Jl. Pendidikan No.7 Kel. Tana Jaya Kec. Kajang Jl. Pendidikan No.7 Kel. Tana Jaya Kec. Kajang

FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM

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

No.Ident : ..................................................................................... No.Ident: ....................................................................................
Umur : ..................................................................................... Umur : ....................................................................................
Alamat : ..................................................................................... Alamat : ....................................................................................
Tanggal : ..................................................................................... Tanggal : ....................................................................................

DARAH RUTIN IMMUNOLOGI/SEROLOGI DARAH RUTIN IMMUNOLOGI/SEROLOGI

Hemoglobin Widal Hemoglobin Widal
Leukosit Golongan Darah Leukosit Golongan Darah
Trombosit HBsAg Trombosit HBsAg
LED HIV LED HIV
URINALISA Syphilis URINALISA Syphilis
Glukosa Urine Dengue IgG/IgM Glukosa Urine Dengue IgG/IgM
Protein Urine Plano Test Protein Urine Plano Test
Sedimen Urine PARASITOLOGI Sedimen Urine PARASITOLOGI
KIMIA DARAH Mikroskopik Malaria (DDR) KIMIA DARAH Mikroskopik Malaria (DDR)

Gula Darah Puasa/Sewaktu MIKROBIOLOGI Gula Darah Puasa/Sewaktu MIKROBIOLOGI

Asam Urat Sputum BTA Asam Urat Sputum BTA
Kolesterol LAIN-LAIN Kolesterol LAIN-LAIN

PENGIRIM PENGIRIM

DINAS KESEHATAN KABUPATEN BULUKUMBA DINAS KESEHATAN KABUPATEN BULUKUMBA

PUSKESMAS KAJANG PUSKESMAS KAJANG
Jl. Pendidikan No.7 Kel. Tana Jaya Kec. Kajang Jl. Pendidikan No.7 Kel. Tana Jaya Kec. Kajang

FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM

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

No.Ident : ..................................................................................... No.Ident: ....................................................................................
Umur : ..................................................................................... Umur : ....................................................................................
Alamat : ..................................................................................... Alamat : ....................................................................................
Tanggal : ..................................................................................... Tanggal : ....................................................................................

DARAH RUTIN IMMUNOLOGI/SEROLOGI DARAH RUTIN IMMUNOLOGI/SEROLOGI

Hemoglobin Widal Hemoglobin Widal
Leukosit Golongan Darah Leukosit Golongan Darah
Trombosit HBsAg Trombosit HBsAg
LED HIV LED HIV
URINALISA Syphilis URINALISA Syphilis
Glukosa Urine Dengue IgG/IgM Glukosa Urine Dengue IgG/IgM
Protein Urine Plano Test Protein Urine Plano Test
Sedimen Urine PARASITOLOGI Sedimen Urine PARASITOLOGI
KIMIA DARAH Mikroskopik Malaria (DDR) KIMIA DARAH Mikroskopik Malaria (DDR)

Gula Darah Puasa/Sewaktu MIKROBIOLOGI Gula Darah Puasa/Sewaktu MIKROBIOLOGI

Asam Urat Sputum BTA Asam Urat Sputum BTA
Kolesterol LAIN-LAIN Kolesterol LAIN-LAIN

PENGIRIM PENGIRIM
 PEMERINTAH KABUPATEN HALMAHERA TIMUR PEMERINTAH KABUPATEN HALMAHERA TIMUR
DINAS KESEHATAN DINAS KESEHATAN
PUSKESMAS MABAPURA PUSKESMAS MABAPURA
Jl.Siswa Desa Soasangaji. Kec.Kota Maba.Kode Pos.97862. Tlp.08114381850 Jl.Siswa Desa Soasangaji. Kec.Kota Maba.Kode Pos.97862. Tlp.08114381850
Email: pkmmabapura@gmail.com Email: pkmmabapura@gmail.com

FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM

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

No.Ident : ..................................................................................... No.Ident : ....................................................................................

Umur : ..................................................................................... Umur : ....................................................................................

Jenis Kelamin :L/P Jenis Kelamin :L/P

Alamat : ..................................................................................... Alamat : ....................................................................................

Tanggal : ..................................................................................... Tanggal : ....................................................................................

Status : BPJS Status : BPJS
JKD JKD
UMUM UMUM
DARAH RUTIN IMMUNOLOGI/SEROLOGI DARAH RUTIN IMMUNOLOGI/SEROLOGI
Hemoglobin Golongan Darah Hemoglobin Golongan Darah
Anti HBsAg (Rapid TesT) Anti HBsAg (Rapid TesT)
Anti HIV (Rapid Test) Anti HIV (Rapid Test)
Syphilis Syphilis

URINALISA PARASITOLOGI URINALISA PARASITOLOGI

Glukosa Urine Mikroskopik Malaria (DDR) Glukosa Urine Mikroskopik Malaria (DDR)
Protein Urine RDT Malaria Protein Urine RDT Malaria
Urine Rutin MIKROBIOLOGI Urine Rutin MIKROBIOLOGI
Sputum BTA Sputum BTA
KIMIA DARAH KIMIA DARAH
Gula Darah Puasa/Sewaktu LAIN-LAIN Gula Darah Puasa/Sewaktu LAIN-LAIN
Asam Urat …................ Asam Urat …................
Kolesterol Kolesterol
Pengirim Pengirim

PEMERINTAH KABUPATEN HALMAHERA TIMUR DINAS KESEHATAN KABUPATEN HALMAHERA TIMUR

DINAS KESEHATAN DINAS KESEHATAN
PUSKESMAS MABAPURA PUSKESMAS MABAPURA
Jl.Siswa Desa Soasangaji. Kec.Kota Maba.Kode Pos.97862. Tlp.08114381850 Jl.Siswa Desa Soasangaji. Kec.Kota Maba.Kode Pos.97862. Tlp.08114381850
Email: pkmmabapura@gmail.com Email: pkmmabapura@gmail.com

FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM

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

No.Ident : ..................................................................................... No.Ident : ....................................................................................

Umur : ..................................................................................... Umur : ....................................................................................

Jenis Kelamin : L / P Jenis Kelamin : L / P

Alamat : ..................................................................................... Alamat : ....................................................................................

Tanggal : ..................................................................................... Tanggal : ....................................................................................

Status : BPJS Status : BPJS
JKD JKD
UMUM UMUM
DARAH RUTIN IMMUNOLOGI/SEROLOGI DARAH RUTIN IMMUNOLOGI/SEROLOGI
Hemoglobin Golongan Darah Hemoglobin Golongan Darah
Anti HBsAg (Rapid TesT) Anti HBsAg (Rapid TesT)
Anti HIV (Rapid Test) Anti HIV (Rapid Test)
Syphilis Syphilis
URINALISA PARASITOLOGI URINALISA PARASITOLOGI
Glukosa Urine Mikroskopik Malaria (DDR) Glukosa Urine Mikroskopik Malaria (DDR)
Protein Urine RDT Malaria Protein Urine RDT Malaria
Urine Rutin MIKROBIOLOGI Urine Rutin MIKROBIOLOGI
Sputum BTA Sputum BTA
KIMIA DARAH KIMIA DARAH
Gula Darah Puasa/Sewaktu LAIN-LAIN Gula Darah Puasa/Sewaktu LAIN-LAIN
Asam Urat …................ Asam Urat …................
Kolesterol Kolesterol

Pengirim Pengirim