7/26/2019 Blangko Permintaan Lab

http://slidepdf.com/reader/full/blangko-permintaan-lab 1/2

FKTP PUSKESMAS UJUNGLOE

PERMINTAAN PEMERIKSAAN LABORATORIUM

Mohon dilakukan pemerikaan !erhadap paien"peer!a kami#

Nama $%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

No% Kar!u $%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Berupa pemerikaan $

G&S $%%%%%%%% T& $%%%%%%%%

G&P $%%%%%%%% TB $%%%%%%%%

G&PP $%%%%%%%% BB $%%%%%%%%

A!a ker'aaman(a kami u)apkan !erima kaih%

Bulukum*a#%%%%%%%%%%%%%%%%%%%%+,-.

&ok!er pemerika

/&r%Pu!ri Fe*rian!(0

FKTP PUSKESMAS UJUNGLOE

PERMINTAAN PEMERIKSAAN LABORATORIUM

Mohon dilakukan pemerikaan !erhadap paien"peer!a kami#

Nama $%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

No% Kar!u $%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Berupa pemerikaan $

G&S $%%%%%%%% T& $%%%%%%%%

G&P $%%%%%%%% TB $%%%%%%%%

G&PP $%%%%%%%% BB $%%%%%%%%

A!a ker'aaman(a kami u)apkan !erima kaih%

Bulukum*a#%%%%%%%%%%%%%%%%%%%%+,-.

&ok!er pemerika

/&r%Pu!ri Fe*rian!(0

7/26/2019 Blangko Permintaan Lab

http://slidepdf.com/reader/full/blangko-permintaan-lab 2/2