RUMAH SAKIT SANTA ELISABETH

Jl Gusti hamzah No.29 Sambas 79400

Telepon: (0562) 391648, Fax: 392408,
INSTALASI RADIOLOGI ( RADIODIAGNOSTIK )

FORMULIR PEMERIKSAAN RADIOLOGI

Nama : Dokter Pengirim :

Umur : (LK/PR) Tanggal :
Nomor MR : Rawat Jalan/ Rawat Inap
Alamat : UMUM / BPJS/ REKANAN :
No Telp :

KONVENSIONAL
1 Schedel AP 34 Humerus AP
2 Schedel Lat 35 Humerus Lat
3 Orbita 36 Elbow Joint AP
4 Orbita Lat 37 Elbow Joint Lat
5 Mandibula AP 38 Antebrachi AP
6 Mandibula Lat 39 Antebrachi Lat
7 Panoramic 40 Wrist Joint AP
8 Waters 41 Wrist Joint Lat
9 Caldwell 42 Manus AP
10 Nasal AP 43 Manus Lat
11 Nasal Lat 44 Femur AP
12 Cervical AP 45 Femur Lat
13 Cervical Lat 46 Hip Joint AP
14 Cervical Oblique 47 Hip Joint Lat
15 Thorax PA / AP 48 Knee Joint – Genu AP
16 Thorax Lateral 49 Knee Joint – Genu Lat
17 Thorax Oblique 50 Patella AP
18 Thorax Top Lordotik 51 Patella Lat
19 Thoracal AP 52 Cruris AP
20 Thoracal Lateral 53 Cruris Lat
21 Thoracal Oblique 54 Ankle
Catatan Joint AP :
/Keterangan
22 Thoracolumbal AP 55 Ankle Joint Lat
23 Thoracolumbal Lat 56 Pedis AP
24 Thoracolumbal Oblique 57 Pedis Lat
25 Lumbal AP 58 Calcaneus
26 Lumbal Lat EKG
27 Lumbal Oblique
28 Pelvic AP USG
29 Pelvic Oblique Diagnosa / Klinis :
30 Coccygeus AP
31 Coccygeus Lat
32 Abdomen / BNO Catatan / Keterangan :
33 Abdomen 3 posisi
34 Clavicula
35 Scapula AP
Sambas,………………20…..
36 Scapula Lat
37 Shoulder Joint AP
38 Shoulder Joint Lat
Beri tanda (√) dr.
Dekstra/Sinistra cantumkan di sebelahnya ( dokter yang meminta)