GSILab

Registered Office: GrahaMitra, 4th Floor,Jl.Jend.Gatot Subroto Kav.21,Jakarta 12930,Indonesia

LabAddress: Jl.RA Kartini No34,Cilandak Jakarta 12430,Indonesia
Instagram: @gsilab.id Email: helpline@gsilab.id
www.gsilab.id
Keputusan DirekturJenderalPelayananKesehatan Broughtto youby 24/7Helpline+62-21-80866080&WA+62-82
Nomor:HK.02.02/I/2932/2020 1-2233-6080

Patient: LUSIA STEFINA KEMBAREN Provider:

GRIYA KENARI MAS C.9/05 RT 004 RW 011, PRAKTEK DOKTER – DR PUTRI ROSINTAN JULIANE
DESA CILEUNGSI KIDUL, KEC. CILEUNGSI, KLINIK QQ MP
BOGOR
Corporate:
Passport /NIK : 3201074902940004 PRAKTEK DOKTER –DR PUTRI ROSINTAN JULIANE
Date of Birth : 09-February-1994 KLINIK QQ MP

Telephone : 081282022963
Email : stefinalusia@gmail.com
Gender : Female
Nationality : INDONESIA

Customer Reference#:

Sample# : 100-106-6223 (995221) DateReceived : 21-February-2022

Source : Swab Nasopharyngeal and Oropharyngeal DateReported : 21-February-2022
Date Collected : 21-Feb-2022 08:48 GMT +7

Test Result ` Normal Range Date Approved

RT-PCRSARS-CoV-2 Negative Negative 21-Feb-2022

E Gene Negative Negative
E Gene Ct -
ORF1ab Gene Negative Negative
ORF1ab Gene Ct -

Note
1. Pemeriksaan menggunakan metode qRT-PCR dan hanya menggambarkan kondisi saat pengambilan spesimen.The above examination result was carried out using
qRT PCR method and only descr ibes the condition of the specimen examined.
2. Pemeriksaan qRT-PCR yang dilakukan merupakan pemeriksaan yang mendeteksi mater i genetic vir us,tanpa membedakan viabilitas vir us(hidup atau mati).qRT
PCR assay only detects genetic materials of vir us,without the ability to distinguish viability of virus.

3. Penentuan status infeksi maupun selesainya masa isolasi individu tidak dapat didasarkan hanya pada hasil qRT-PCR; melainkan membutuhkan pertimbangan
kondisi
klinis,riwayat penyakit dan pemeriksaan penunjang lainnya. Infection status or end of isolation time cannot be solely determined from RT-PCR result;
combination of
data related to clinical manifestation,course of disease and other supporting examinations are required.

4. Hasil qRT-PCR serta nilai Ct tidak dapat dibandingkan antara satu laboratorium dengan laboratorium lain ;mengingat adanya variasi nilai Ct untuk alat, metode,reagen
Yang di gunakan serta gentarget yang diperiksa.qRT-PCR result nor Ct value should not be compared between laboratories since a wide variety of Ct values have been
reported due to tools, methods, reagents and targeted genes used.

Approved By : dr. Louisa M.Sp.PK

21-February-2022

PrintDate:21-Feb-2022
Page 1 of 1
 SURAT KETERANGAN DOKTER
MEDICAL CERTIFICATE
Yang bertanda tangan 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 : LUSIA STEFINA KEMBAREN

Passport /NIK : 3201074902940004
TanggalLahir/DOB : 09-February-1994
Domisili /Address : GRIYA KENARI MAS C.9/05 RT 004 RW 011, DESA CILEUNGSI KIDUL,KEC.
CILEUNGSI,BOGOR
Perusahaan/Company : PRAKTEK DOKTER – DR PUTRI ROSINTAN JULIANE, KLINIK QQ MP

Fasyankes/Provider : PRAKTEK DOKTER – DR PUTRI ROSINTAN JULIANE, KLINIK QQ MP

Kewarganegaraan/Nationality : INDONESIA
email /email : stefinalusia@gmail.com

Dilakukan pemeriksaan / Sample Examination:

Sampel / Sample # : 100-106-6223(995221) Tgl Penerimaan / DateReceived : 21-Feb-2022

Sumber / Source : Swab Nasopharyngeal and Tgl Pelaporan / DateReported : 21-Feb-2022
Oropharyngeal
Tgl Pengumpulan / Date Collected : 21-Feb-2022 08:48 GMT+7

Test Result Normal Range Date Approved

RT-P C R S A R S -CoV-2 Negative Negative 21-Feb-2022

E Gene Negative Negative
E Gene Ct -
ORF1ab Gene Negative Negative
ORF1ab Gene Ct -

Demikian surat keterangan ini dibuat untuk digunakan sebagaimana mestinya.

This certificate is made to be used as intended.

Terima kasih atas perhatiannya,

Thank you for your attention,
Pindai untuk periksa keaslian dokumen
Scan to check document's originality
Hormat kami,
Sincerely,
Jakarta, 21 February 2022

dr. LouisaM.Sp.PK
SIP No. 88/B.15B/31.74.06.1001.06.004.K.3.a.b/3/-1.779.3/e/2021
PT.Genomik Solidaritas Indonesia
Registered Office: GrahaMitra,4th Floor,Jl.Jend. Gatot Subroto Kav.21,Jakarta 12930,Indonesia
Lab Address: Jl.RA Kartini No 34,Cilandak Jakarta 12430,Indonesia
T: +622150209090 F:+622125579889