KLINIK AN-NAWAWI

Dsn Dempul Lor FORMULIR PERMINTAAN

RT.001 RW.001 Ds Mojogebang
Kec Kemlagi – Kabupaten Mojokerto
PEMERIKSAAN LABORATORIUM
Telp: 081249270207
Email : klinikannawawi@gmail.com

No. Lab : ...........................

Tgl. : …………................

Nama Pasien : .................................................................................. Dokter Pengirim : ..................................................................................

No. RM : .................................................................................. Alamat : ..................................................................................
Alamat : .................................................................................. No. Tlp : ..................................................................................
TTL : .................................................................................. Tanggal : ..................................................................................
Diagnosa : ..................................................................................
HEMATOLOGI KIMIA DARAH IMUNOSEROLOGI DAN SEROLOGI

O Hematologi Automatic O Glukosa Puasa* O Anti HAV Total O Widal

(Hb, Leko, Hct, Trombosit) O Glukosa 2 jam PP O Anti HAV IgM O Anti Salmonella Typhi IgM (Tubex
O Hematologi Lengkap O Glukosa Sewaktu O HbsAg Rapid TF)
(Hb, Leko, Hct, Trombosit, Diff, LED) O Glukosa Toleransi Test* (GTT) O Dengue NS1
O Hemoglobin O HBA1C
O Leukosit O Anti HIV
O Hitung Jenis Leukosit O TPHA
O LED (Laju Endap Darah) O Protein Total O VDRL
O Trombosit O Albumin
O Hematokrit O Globulin
O Eritrosit O SGOT
O Eosinofil O SGPT
O Retikulosit O Bilirubin Total
O Apus Darah Tepi (ADT) O Bilirubin Direk/Indirek

O Ureum / BUN
KLINIK RUTIN O Creatinin
O Asam Urat
O Urine Rutin PATOLOGI ANATOMI
O Sedimen O Cholestrol Total
O PAP Smear
O Glukosa Urine O Trigliserida
O Biopsi / Oprasi
O Protein Urine O HDL-Cholestrol
O Protein Kuantitatif (ESBACH) # O LDL-Cholestrol
O Protein Bence Jones O Total Lipid

O Test Pack (Tes Kehamilan)

DOKTER YANG MEMERIKSA
O Faeces Rutine

KETERANGAN
* Puasa dan dilarang merokok 10-12 jam (dr. ..........................................)
(*) Persiapan pemeriksaan hubungi Laboratorium
# Urine Tampung 24 Jam
O Hasil dikirim ke dokter
O Hasil dikirim ke ruang : ....... PENGAMBILAN SPESIMEN / SAMPEL
O Hasil diserahkan ke penderita
PENGAMBIL PENGIRIM PENERIMA
NAMA PETUGAS
TGL
JAM