GSI Lab

Registered Office: Graha Mitra, 4th Floor, Jl. Jend. Gatot Subroto Kav. 21, Jakarta 12930, Indonesia
Lab Address: Jl. RA Kartini No 34, Cilandak Jakarta 12430, Indonesia
Instagram : @gsilab.id Email : helpline@gsilab.id
www.gsilab.id
Keputusan Direktur Jenderal Pelayanan Kesehatan Brought to you by 24/7 Helpline +62-21-8086 6080 & WA +62-821-2233-6080
Nomor: HK.02.02/I/2932/2020

Patient: DWI INDRAYANTI Provider:

VKGY2K-3661 KLINIK PRATAMA HALOMEDIKA
Corporate:
Halodoc Org
Local ID / NIK : 3173015602780009

Date of Birth : 16-February-1978

Telephone : 087794900921

Email : lab.ihs@mhealth.tech

Gender : Female

Report # :
Customer Reference # :

Sample # : 100-014-6792 (143063) Date Received : 14-November-2020

Source : Swab, Naso-Oropharyngeal Date Reported : 15-November-2020
Date Collected : 14-November-2020

Test Result Normal Range Date Approved

PCR SARS-CoV-2 Presumptive Positive/Inconclu Negative 14-Nov-2020

sive
E Gene Positive Negative
E Gene Ct 31.15
RdRp Gene Negative Negative
RdRp Gene Ct -

Approved By : dr. Siskawati Suparmin, Sp.PK.

15-November-2020

Page 1 of 1 Print Date: 15-Nov-2020

 SURAT KETERANGAN DOKTER
MEDICAL CERTIFICATE
Yang bertandatangan dibawah ini dokter Laboratorium Genomik Solidaritas Indonesia (GSI Lab), menyatakan bahwa :
The undersigned, the Genomik Solidaritas Indonesia Laboratory Physician (GSI Lab), explains that:

Nama / Name : DWI INDRAYANTI

NIK / Local ID : 3173015602780009

Tanggal Lahir / DOB :16-February-1978

Domisili / Address : VKGY2K-3661

Perusahaan / Company : Halodoc Org

Fasyankes / Provider : KLINIK PRATAMA HALOMEDIKA

Dilakukan pemeriksaan :

Sampel / Sample # : 100-014-6792 (143063) Tgl Penerimaan / Date Received : 14-Nov-2020

Sumber / Source : Swab, Naso-Oropharyngeal Tgl Pelaporan / Date Reported : 15-Nov-2020
Tgl Pengumpulan / Date Collected : 14-Nov-2020

Test Result Normal Range Date Approved

PCR SARS-CoV-2 Presumptive Positive/Inconcl Negative 14-Nov-2020

usive
E Gene Positive Negative
E Gene Ct 31.15
RdRp Gene Negative Negative
RdRp Gene Ct -

Demikian surat keterangan ini dibuat untuk digunakan sebagaimana mestinya.

This certificate is made to be used as intended.

Terimakasih atas perhatiannya,

Thank you for your attention,
Pindai untuk periksa keaslian dokumen
Scan to check document's originality

Hormat kami,
Sincerely,

Jakarta, 14 November 2020

dr. Siskawati Suparmin, Sp.PK.

SIP No. 93/B.15B/31.74.06.1001.06.005.K.3.a.b/3/-1.779.3/e/2020

PT. Genomik Solidaritas Indonesia

Registered Office: Graha Mitra, 4th Floor, Jl. Jend. Gatot Subroto Kav. 21, Jakarta 12930, Indonesia
Lab Address: Jl. RA Kartini No 34, Cilandak Jakarta 12430, Indonesia
T : +6221 5020 9090 F : +6221 2557 9889