CITO murat INSTALASI LABORATORIUM KLINIK [_____._ RATNA CHARITAS HOSPITAL BELITANG ‘Nama Pasien tafoaii9e0 Jn, Charitas No. BK. 10 Tegal Rejo Belitng z testes Teip. (0735 ) 450066 Fax. ( 0735 ) 451959 Tanggal Lahir WOSFIAS Email : laboratoriumcharitasbelitang@ gmail.com No. RM. Jenis Kelamin Diagnosis CA Satie. Vnditnn. 28. ‘Alamat Kamar Dokter Pengirim Ringkasan. Klinis Tal. Order No Lab as aiatcln FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM. : [ HEMATOLOGT FUNGSI GINJAL HEPATITIS | D Paket Darah Lengkap/CBC OG Ureum ‘Anti HCV (Hemoglobin, Hematokrit, O Creatinin HBsAg ‘Trombosit, Leukosit, Eritosit, |) Asam Urat EKTROLIT ie Come MCHC, LED, | FUNGSI HATI CO Paket Elektrolit (Na, K, Cl) | po Paket Darah Rutin 0 Tosa Protea TF Nats (Na) (Hemoglobin, Hematokrit, | 2 Albumin OO Kalium (K) Trombosit, Leukosit,Eritrosit) |) Globulin Oi Kiorida (Cty |G Hemoglobin O scot SEROLOGI O Leukosit G sorr O wipat DO Eritrosit | Oi Alkali Phospatase D NSI Dengue Ag CO Trombosit © Bilirubin Total ‘Anti HIV Ci Hematoksit O Bilirubin Direk pone TPHA Ol cv, McH, MCHC O Bilirubin indirek paET LED LEMAK O Secret Vagina = Sree |S ssc /,2, Golongan Darah Cholesterol HDL Secret Mata on © Cholesterol LDL br eertae STASIS O Trigliserida O Urine Rutin ‘Waktu Pendarahan (BT) HORMON* 2, Prpjata ine Waktu Pembekuan (CT) D Tsu* © Tes Kehamilan MIKROBIOLOGI O Free T3* OC Keton Urine CO Sputum BTA O Free T4* LAIN LAIN Gi Malaria DDR Ot OD Analie Sperma DIABETES O ta CO Faeces Rutin OO Gtukosa Puasa REMATIK C,, Glukosa 2 Jam PP Casto Bp Glukosa Sewaktu O rr O npaic O CRP Kuantitatit Peugas Sampling py, | Kuali Sapa y | Jam Sampling jy y= | Jam Keluar bas 9 *Pemeriksoan Dieu Dokteg Pengirim, lg