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PEMERINTAH KABUPATEN BONEDINAS KESEHATANUPTD. PUSKESMAS BAJOE KEC. TANETE RIATTANG TIMURJl. Yos Sudarso No. 294 T!l". #$4%&' 2(&(% Ba)oEFORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM PUSKESMASPasien :Nomor Register: ...............................................Nama :...............................................Tgl.Lahir/Umur:...............................................Jenis Kelamin : ...............................................Alamat : ...............................................BajoE,.............................. 2.... !o"ter/Pengirim,# ................................................. $PEMERINTAH KABUPATEN BONE%&esimenJenis :............................Asal Bahan : ............................Tgl/jam &engam'ilan s& : ........................................................Petugas : ...........................Gejala Penyakit :Pengo'atan :K()(A KL(N(K* Glukosa* Protein* Albumin* Bilirubin Total* Bilirubin Direk* SGOT* SGPT* Alkali Fosfatase*Asam Urat* Ureum / BUN* Kreatinin* Triliseri!a* Kolesterol Total* Kolesterol "D#* Kolesterol #D#+AE,E%* $akrosko%is & Konsistensi & 'arna & Bau & #en!ir & Dara(* Dara( Samar* $ikrosko%is & Telur )a*in & Amuba & +ritrosit & #eukosit & Sisa $akanan-2./01234-2./01234----25E)AT6L67(* "emolobin ,"b- * "ematokrit * "itun eritrosit* "itun Trombosit* "itun #ekosit* "itun .enis #ekosit* #aju +n!a% Dara(* $asa Per!ara(an * $asa PembekuanU/0NA#0SA * $akrosko%is & 'arna & Kejerni(an * & Bau * & 1olume * P" * Berat .enis * Protein * Glukosa * Bilirubin * Urobilinoen * Keton * Nitrit * #ekosit * +ritrosit * * Se!imen* -2./01234----2-.-/-0-2. )(KR6B(6L67( 8* PARA%(T6L67(* $y*oba*terium* Neisseria onnor r(oeae * Tri*(omonas 2ai nalis* )an!i!a albi*ans* Ba*terial 2ainosis* $alaria* $i*ro3laria* .amur Permukaan0$UNO#OG0* Tes Ke(amilan* Golonan Dara(* '0DA#* 1D/#* "BsA* Anti "01* Antien/ Antibo!y Denue* #ain&lain :-2./0123-2./012.+N0S P+$+/0KSAAN No.+N0S P+$+/0KSAA No.+N0S P+$+/0KSAAN NoDINAS KESEHATANUPTD. PUSKESMAS BAJOE KEC. TANETE RIATTANG TIMURJl. Yos Sudarso No. 294 T!l". #$4%&' 2(&(% Ba)oEFORMULIR PERMINTAAN RUJUKAN PEMERIKSAAN LABORATORIUM PUSKESMASPasien/Spesimen RujukanPasien :Nomor Register: ...............................................Nama :...............................................Tgl.Lahir/Umur:...............................................Jenis Kelamin : ...............................................Alamat : ...............................................BajoE,.............................. 2.... !o"ter/Penanggung Ja9a',Pemeri"sa,# ........................................ $# ................................................ $PEMERINTAH KABUPATEN BONEDINAS KESEHATAN%&esimenJenis :............................Asal Bahan : ............................Tgl/jam &engam'ilan s& : ........................................................Petugas : ...........................Gejala Penyakit :Pengo'atan :K()(A KL(N(K* Glukosa* Protein* Albumin* Bilirubin Total* Bilirubin Direk* SGOT* SGPT* Alkali Fosfatase*Asam Urat* Ureum / BUN* Kreatinin* Triliseri!a* Kolesterol Total* Kolesterol "D#* Kolesterol #D#+AE,E%* $akrosko%is & Konsistensi & 'arna & Bau & #en!ir & Dara(* Dara( Samar* $ikrosko%is & Telur )a*in & Amuba & +ritrosit & #eukosit & Sisa $akanan-2./01234-2./01234----25E)AT6L67(* "emolobin ,"b- * "ematokrit * "itun eritrosit* "itun Trombosit* "itun #ekosit* "itun .enis #ekosit* #aju +n!a% Dara(* $asa Per!ara(an * $asa PembekuanU/0NA#0SA * $akrosko%is & 'arna & Kejerni(an * & Bau * & 1olume * P" * Berat .enis * Protein * Glukosa * Bilirubin * Urobilinoen * Keton * Nitrit * #ekosit * +ritrosit * * Se!imen* -2./01234----2-.-/-0-2. )(KR6B(6L67( 8* PARA%(T6L67(* $y*oba*terium* Neisseria onnor r(oeae * Tri*(omonas 2ai nalis* )an!i!a albi*ans* Ba*terial 2ainosis* $alaria* $i*ro3laria* .amur Permukaan0$UNO#OG0* Tes Ke(amilan* Golonan Dara(* '0DA#* 1D/#* "BsA* Anti "01* Antien/ Antibo!y Denue* #ain&lain :-2./0123-2./012.+N0S P+$+/0KSAAN No.+N0S P+$+/0KSAA No.+N0S P+$+/0KSAAN NoUPTD. PUSKESMAS BAJOE KEC. TANETE RIATTANG TIMURJl. Yos Sudarso No. 294 T!l". #$4%&' 2(&(% Ba)oEFORMULIR HASIL PEMERIKSAAN LABORATORIUM PUSKESMASPasien :Nomor Register: ...............................................Nama :...............................................Tgl.Lahir/Umur:...............................................Jenis Kelamin : ...............................................Alamat : ...............................................BajoE,.............................. 2.... !o"ter/Penanggung Ja9a',Pemeri"sa,# ....................................... $ # ................................................. $%&esimenJenis :............................Asal Bahan : ............................Tgl/jam &engam'ilan s& : ........................................................Petugas : ...........................Gejala Penyakit :Pengo'atan :45&665m/!l789&:8;m/!l686m/!l

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