FORM PERMINTAAN PEMERIKSAAN

LABORATORIUM

Nama Pasien : ....................................................

No. RM : ....................................................
Tanggal Pelayanan : ....................................................
Ruang / Poli : ....................................................
Dokter Pengirim : ....................................................

HEMATOLOGI GULA DARAH BAKTERIOLOGI

Darah rutin Gula darah sewaktu Sputum BTA
Hemoglobin Gula darah 2 jam pp BTA Hansen
Hematokrit Gula darah puasa Preparat GO
Leukosit URINE Difteri
Trombosit Makroskopis Gram
Hitung jenis leukosit Warna Sekret KOH
LED Kejernihan HIV test
Eritrosit Darah IVA TEST
Diff Count Mikroskopis SEROLOGI
Golongan darah+rhesus Epitel Widal Test
CT/BT Leukosit Hbs Ag
MCV Eritrosit Malaria Rapid Test
MCH Silinder Narkoba
Apusan Darah Tepi Kristal HIV test
KIMIA DARAH Bakteri FAECES
SGOT Kimia Urine Faeces rutin
SGPT Berat jenis Malaria / DDR
Billirubin Total pH
Billirubin Direct Leukosit
Billirubin Indirect Nitrit
Total Protein Reduksi
Albumin Protein
Globulin Urobilinogen
Asam Urat Bilirubin
Alkali Fosfatase Blood
Ureum Keton
Kreatinin PP test
Kolesterol
Trigliserida
HDL Cholesterol

LDL Cholesterol

Tanda Tangan Pasien Tanda Tangan Dokter

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