Permintaan Pemeriksaan Radilogi

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PEMERINTAH KOTA MALANG

RUMAH SAKIT UMUM DAERAH

Disi oleh petugas KOTA MALANG
Radiologi Jl. Rajasa Kelurahan Bumiayu Kode Pos 65135

Baru PERMINTAAN PEMERIKSAAN RONTGEN / USG

Ulangan
Harap foto Ro / USG lama dilampirkan

No. Reg. Ro: / Thn

Nama : …………………………….. No. RM
…………….…. / …..…………….
Jenis Kelamin : Laki – laki / Perempuan, Umur :
Index : ………………………..
Poliklinik / Ruangan : ……………………………….
…………...…..
Keterangan klinis / lab :
Catatan :
……………………………………………...
………………………………………………………………………
………………………………………………………………………

Pemakaian Film Ro.

………………………………………………………………………
………………………………………………………………………
……………………
Permintaan fto Ro / USG :
……………………………………………..
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………

Malang,
……………………….
Tanda Tangan Dokter
( …………………………. )
NIP.

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