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‘PENGENDALIANTS WASIOWAL Cons FORMULIR PERMOHONAN LABORATORIUM TS UNTUK PEMERIKSAAN DAHAK Noma Fasyankes oT Nara Tn A Kis (TAK) Naa up pasion SESE towel a [TE] hin denis Ketamin ‘Lakttaxi [] Perempuan [] ‘maton ae atupaten Kota ey eax Proving Orv © temor No. entiss Sedan Guin noRep Suspat TAOS THOBNOR) || Alasan Pomartzaan See ee Doo C] “et Pengamian ak teat |} reew ep pngatn “anal pengman seiaan fuente: [-] Td tangen pegar eon Followup paca pongebeton ans & Jumioh Pemerisaan | Rialiaal Paya Bulan ke I Tes Copat ru] Oo erax erapaw |] Nosteg tarts OR Fasy Batons oat: No Rog TE/TB MOR Kab 1 oiepaczan in Sees VET RT 1 Uikepekaan Lint 2 Nanah lend :S [_] fercakdarah ¢ (C] ator :8 J ‘Sats HY Po °o °ol 1 Fon so so aE) E) negatt 20, ee Fie Specimen To eae ‘ i tare Nama ela ote engi ether e HASIL PEMERIKSAAN LABORATORIUM No. Register Leb. (sesuai dengan Formul dl TB.04/TB.04 MOR). ‘Spesimen dahak? | Tanggal hasit Hesil BTA” rr = = ra Tea Poi Specimen dabok) | Tao Hast Tes Capa pen MTR? feos Rea ie Rik A al Tas oa | Bo RE SevaitaPogt 1 Spesiencanak? | Tonga! Host Hest iar? a eT a: a zy 7 esi kapeias™ specimen davak” | Tongattast | 75 ast eosin Ss Mongsan Tende argan purer ok Pl aeranan Lab t ae) ‘ ) 1) Din dg neat ent Sheps ee a Sh btn te pec i BAER haan fn ga {hela ana sett ag mya gs eR an ‘kaos an i na mee man ae ah tena gen wr ao argh many 9 ory moni as se

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