RS a RUMAH SAKIT Bun 41. Kosambl Timur Raya No. 2 RT. 011/004 (Pertigaan Kosambi Timur - Barat) Kel. Kosambi Timur Kec. Kosambi, Tangerang 15213, Telp, 021 - 2903 1659 HASIL PEMERIKSAAN Ponanggung Lab: dr Fronsisca Mula, Sp.PK Penanggung uum ‘Nomat + Jk Raya Kosambl Timur No.2. Kel. Kosambl —Doktar (, Eleonora Vania ineza Timur, Keo. Kosambi, Kosar NNo.Rm/Ruang 000054969 / 10 Kun /Tol (62451 31/08/2021 16.06 No. tab/ Tol: 31976/ 31/08/2021 16:26 Jenis Kelamin = LAKLLAKI 'SAFRUDIN Tal Lahie/ 7108/1984 KP. Gunung RLS/16 Telepon 081818184567) Pemeriksaan Hasit ‘Nilai Rujukan Satuan Keterangan TAINAN SWAB ANTIGEN Cov-2 Negatit NEGATIVE Non Reakiif Untuk hasil post akukan konfirmasi dengan metode PCR ‘. Fransisca Mulyadi, Sp.PK Nas Hern A. ed Kas Penanggung Jawab Dipindai dengan CamScannerWealth Dectarmion form to Prevent Cond-12 ame vay rH ViTOR wail Nama Pecusaaan/Compans Name + PT Cote Ulemm Qeoqn No. Passprt/ Passport No " ral @ No HP/Phone No 0818 (418.45 67 Talom Kenjangns Vii Pepeee + Macan Bee Tange Kenji / Vel Date | Sersyac aA Jam Tine ¢ 7.99 PIC yangdtju/ PIC Addressed +, Veworesyes Divi Dion Neg amie Dm estan dan esata Dera dip er, nds has JUJUR meal dengan mening (AFD ikem jaan wink De sfers reson please ones fl tee questions belo byes the anne (YES NO} Dalam 14 hari terakhir. apakah anda pernah mengalami hal-hal bert In the last 1d Days, have you ever been inthis situation [Total Scare [bagian ini dsl oleh HSE HMSI/ This Part is filed in by the HSE of HMAS!] Tae - PERTANYAAN Se ursTion Ta | AR ra_| "wo i a eratviaps a wt Petar one a n | @ eater ea mei ton 7 = |Have you use public transport in the last 14 days ? eS = 5, ees eos aE ce ir no gel yer pega aor wales 4 [isthe gen bya a? ~ (eDul SiGe oe aaa we tear Gs Cn eat (mt ih a i ti er eoney a ae De [Have you get fever ‘cough / cold / sore throat / hard breathing ? a frame was melampiran Copy has Rapid ts dg hast Non Reaktt / Negatf yang masin berlku, malsimal 14 hal setlsh pengambilansampel epi) vets ove required to otocho copy ofthe Rapid tes results wth Nom Reactive / Negative resus fwhich are stil vali 2 max of 14 day ofter rep samging) nencanakunjangan dapat tla apa toa ila melebi etentuan / The vs plan can be ejected if he total wale exceeds the provisions ote Tash Format Rem na T3746 dengan engl [please il ie orm compte Items no. unt6 22 _Kinmfan ke HSE PT HMS! 31 har sl kunjngan / send to HSE of he PWM) 3 days porto your vst ‘Me aN: -mall ka Nuradelei@hino.coid stake) ‘Me Matlina E-mail: Marinatehino.coid (MTA) 2 Formulirndberoku 7 har sels anges pengltan / TMs forms valid for 7 days Lromthe dota fog JTANDA TANGAN TAMU /Sign of Visitor |KOLOM IN IIS! OLEH PENGUNDANG / This Colour i filled in by Inviter |Fanesat penealuan Formuke J Bote of Submission form eee ns reensne/nter rane eel viniathep om, fatieas Dr Head) lands Tang ep Du Hea Signature Jowctun olen nse /nst acnowesee Diterima / Ditolak* Accepted / Denied* faite >> Dipindai dengan CamScanner