dr.

MARTIN AGUSTA
SIP : 03/SIPD-DPMPTSP/I/2021
Jl. Jawa rt/rw.001 Kel. Binuang Kec. Binuang Kab. Tapin Prov. Kalimantan Selatan
Email : martinagusta@yahoo.co.id hp: 082282204699

RESULT OF
PRO ACTIVE TEST COVID-19

TEST NAME : IDENTIFICATION CORONA VIRUS DISEASE (COVID-19)

METODE : SWAB ANTIGEN COVID-19
SPECIMEN MATERIAL : NASAL SMEAR
SAMPLE DATE : 02 Maret 2021

No. Sample code Name Sex Age Adress Result Reference Range

1. Dr.Ma/III/013 Mrs. Dwi Kristina F 21 y.o Tambakasari Negative Negative

Wetan Kel.
Sidoasri Kec.
Sumbermanjingw
etan Kab. Malang
Prov. Jawa
TIMUR

Note :
*Complete
interpretation need
clinical data and
supportive data.
Negative PCR result
only shows that the
pathogenic genetic
material in question
is not found in the
specimen

*Laboratory result
interpretation only
given by clinician
whose have the
patient data

*The Doctors not

responsible for result
not taken after 1
months

checked by

e/PST/00/009-00/0120

Hal:1/1@02/03/2021