NO RM : ______________________________ NO RM : ______________________________
TANGGAL : ______________________________ TANGGAL : ______________________________
PEMERIKSAAN : ______________________________ PEMERIKSAAN : ______________________________
ALAMAT : ______________________________ ALAMAT : ______________________________
DR PENGIRIM : ______________________________ DR PENGIRIM : ______________________________
DR RADIOLOGI : ______________________________ DR RADIOLOGI : ______________________________