FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM

No. RM : ....................................... Tgl Permintaan : ........................................

Nama : ....................................... Diagnosa : ........................................
Umur : ......................Tahun L/P Dokter : ........................................
Alamat : .......................................

HEMATOLOGI KIMIA DARAH URINE

 Hematologi Lengkap  Gula Darah Puasa  Urine Lengkap
 Hemoglobin  Gula Darah 2 Jam PP  Protein
 Leukosit  Gula Darah Sewaktu  Glukosa
 Hematrokit  Protein Total  Keton
 Trombosit  Albumin  Urobilinogen
 Retikulosit  Globulin  Bilirubin
 Eritrosit  Bilirubin Total  PH
 LED  Bilirubin Direct  Sedimen
 Waktu Perdarahan  Bilirubin Indirect  Leko/LPB
 Waktu Pembekuan  SGOT  Eri/LPB
 Waktu Protombin  SGPT  Selep/LPB
 Hitung Jenis Leukosit  Ureum  Kristal
 Gol Darah. Rhesus  Creatinin
 Gambaran Darah Tepi  Asam Urat
 Kolesterol SEROLOGI
 HDL  Anti HIV
ELEKTROLIT  LDL  Hbs Ag
 Natrim  Trigliserid
 Kalium
 Clorida

Catatan:

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Dokter Pengirim