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  • Formulir Permintaan Lab

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    samsul
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    This document is a request form from Jepun Klinik in Lombok Barat for laboratory tests. It lists the patient's information such as name, date of birth, address, and doctor requesting the tests. It then provides checkboxes to indicate which tests are needed from categories including hematology, liver function, lipids, microbiology, tuberculosis, stool exam, urinalysis, and others. The form requires the doctor's signature.

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    FORM LAB

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    This document is a request form from Jepun Klinik in Lombok Barat for laboratory tests. It lists the patient's information such as name, date of birth, address, and doctor requesting the tests. It then provides checkboxes to indicate which tests are needed from categories including hematology, liver function, lipids, microbiology, tuberculosis, stool exam, urinalysis, and others. The form requires the doctor's signature.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    59 views2 pages

    Formulir Permintaan Lab

    Uploaded by

    samsul
    This document is a request form from Jepun Klinik in Lombok Barat for laboratory tests. It lists the patient's information such as name, date of birth, address, and doctor requesting the tests. It then provides checkboxes to indicate which tests are needed from categories including hematology, liver function, lipids, microbiology, tuberculosis, stool exam, urinalysis, and others. The form requires the doctor's signature.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    of 2

    JEPUN KLINIK

    Jln. RRI Tegal Jagaraga Kecamatan Kuripan Lombok Barat


    email : jepun.klinik15@gmail.com Telp : +62877 6592 3139

    No. Spesimen : No. RM :


    Nama Pasien : Status pasien : Umum /BPJS
    Tanggal lahir :
    Alamat : Tanda Tangan Dokter pengirim
    Ruang/Poliklinik :
    Diagnosis / Ket. Klinik :

    PERMINTAAN PEMERIKSAAN LABORATORIUM


    Pemeriksaan yang diminta harap diberi tanda ( ) ( * ) Puasa 12 Jam
    HEMATOLOGI FAAL HATI PROFIL LEMAK MIKROB
    Hematologi Rutin Albumin HDL Kolesterol Mikroskopis
    Hematologi Lengkap hemotologi Bilirubin Direk Kolesterol Total Pengecatan Gram
    rutin + LED) hemotologi rutin +
    LED)
    LED Bilirubin Total LDL Kolesterol Direk Pengecatan Jamu
    Golongan Darah A, B, O, dan Rh Fosfatase Alkali Trigliserida ( * ) Preparat Trichom
    FAAL HEMOSTASIS Globulin FAAL GINJAL Kultur dan Sensiti
    APTT SGOT Asam Urat TUBERKU
    PPT SGPT Kreatinin BTA (Mikroskopis
    Waktu Pembekuan ( CT ) Protein Total Urea N ( * ) Kultur BTA
    Waktu Pendarahan ( BT ) DIABETES HEPATITIS ANALISA
    HEMATOLOGI LAIN Glukosa 2 Jam PP Anti - HBs Kualitatif Feses Lengkap
    Hapusan Darah Tepi Glukosa Puasa ( * ) HBsAg Kuantitatif URINA
    Malaria Mikroskopis Glukosa Sewaktu HBsAg Kualitatif Urine Rutin
    ELEKTEROLIT-GAS DARAH HbA1c INFEKSI LAIN Urine Lengkap ( U
    Sedimen Urine )
    Analisa Gas Darah TIROID Anti - HIV
    Na, K, Cl Free T3 Anti Dengue IgG & IgM Tes Kehamilan
    Na, K, Cl Free T4 Malaria PEMERIKSA
    ANALISIS CAIRAN T3 total Widal
    Cairan Serebrosipinal T4 Total NS1 Antigen Dengue
    Cairan Sendi TSHs
    Cairan Pleura
    Cairan Asites
    Barat
    139

    Umum /BPJS

    ngan Dokter pengirim :

    ( * ) Puasa 12 Jam
    MIKROBIOLOGI
    Mikroskopis
    Pengecatan Gram

    Pengecatan Jamur
    Preparat Trichomonas
    Kultur dan Sensitivitas Antibiotik
    TUBERKULOSIS
    BTA (Mikroskopis)
    Kultur BTA
    ANALISA FESES
    Feses Lengkap
    URINALISIS
    Urine Rutin
    Urine Lengkap ( Urine Rutin +
    Sedimen Urine )

    Tes Kehamilan
    PEMERIKSAAN LAIN

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