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  • Pemerintah Kota Tomohon Puskesmas Kakaskasen Puskesmas Kakaskasen

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    This document is a laboratory test request form from Puskesmas Kakaskasen located in Tomohon Utara, North Sulawesi. The form includes fields for the patient's name, medical record number, sex, date of birth, address, insurance, referring doctor, and requested laboratory tests. The tests include hematology, urinalysis, microbiology, and others such as malaria, hepatitis, HIV. At the bottom is a space for diagnosis and notes from the referring doctor.

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    This document is a laboratory test request form from Puskesmas Kakaskasen located in Tomohon Utara, North Sulawesi. The form includes fields for the patient's name, medical record number, sex, date of birth, address, insurance, referring doctor, and requested laboratory tests. The tests include hematology, urinalysis, microbiology, and others such as malaria, hepatitis, HIV. At the bottom is a space for diagnosis and notes from the referring doctor.

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    9 views1 page

    Pemerintah Kota Tomohon Puskesmas Kakaskasen Puskesmas Kakaskasen

    Uploaded by

    apotek puskesmasKakaskasen
    This document is a laboratory test request form from Puskesmas Kakaskasen located in Tomohon Utara, North Sulawesi. The form includes fields for the patient's name, medical record number, sex, date of birth, address, insurance, referring doctor, and requested laboratory tests. The tests include hematology, urinalysis, microbiology, and others such as malaria, hepatitis, HIV. At the bottom is a space for diagnosis and notes from the referring doctor.

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    DINAS KESEHATAN DAERAH

    PEMERINTAH KOTA TOMOHON PUSKESMAS KAKASKASEN


    Alamat : Jln. Puskesmas Kelurahan Kakaskasen Kec. Tomohon Utara
    DINAS KESEHATAN DAERAH Telp. (0431)3159187 Kode Pos 95425
    PUSKESMAS KAKASKASEN
    Alamat : Jln. Puskesmas Kelurahan Kakaskasen Kec. Tomohon Utara FORMULIR PEMERIKSAAN LABORATORIUM PUSKESMAS
    Telp. (0431)3159187 Kode Pos 95425
    Nama : Hari/tgl :
    FORMULIR PEMERIKSAAN LABORATORIUM PUSKESMAS No. RM : JK : L/P
    Nama : Hari/tgl : Alamat : Jaminan : JD/JM/A/I/U/GRATIS
    No. RM : JK : L/P
    Alamat : Jaminan : JD/JM/A/I/U/GRATIS Tgl lahir/umur: Dokter pengirim:
    Tgl lahir/umur: Dokter pengirim: JENIS PEMERIKSAAN
    JENIS PEMERIKSAAN
    1. HEMATOLOGI 3. URINALISA
    1. HEMATOLOGI 3. URINALISA a. Leukosit a. HCG Tes
    a. Leukosit a. HCG Tes b. Eritrosit 4. MIKROBIOLOGI
    b. Eritrosit 4. MIKROBIOLOGI c. Trombosit a. SPUTUM BTA
    c. Trombosit a. SPUTUM BTA d. Hemoglobin 6. Lain-lain
    d. Hemoglobin 5. Lain-lain e. HCT a. Malaria
    e. HCT a. Malaria 2. KIMIA KLINIK b. Hepatitis
    2. KIMIA KLINIK b. Hepatitis a. GDP/ GDS c. IVA
    a. GDP/ GDS c. IVA b. Asam urat d. HIV
    b. Asam urat d. HIV c. Kolesterol total
    c. Kolesterol total

    Diagnosa/ Ket:
    Diagnosa/ Ket:
    Pengirim
    Pengirim

    NIP.
    NIP.

    PEMERINTAH KOTA TOMOHON

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