FM-DEN-11.04-05 Revisi: 00

FM-DEN-11.04-05 Revisi : 00

Jl. Dr. Wahidin Sudirohusodo 736 Gresik Telp. (031) 3950552, 3958499 Fax. (031) 3958599 Gresik  –  61121  61121

FORMULIR RUJUKAN PEMERIKSAAN RADIOLOGI / USG (Foto roentgen lama harap dilampirkan)

Nama

: ............................................... ............................. .................. Usia

: ...................

Alamat

: .............................. ................. Jenis Kelamin : P / L

Poli / Ruangan

: .............................. ................. No Reg

Keterangan Keterangan Klinis

: .............................. .............................. .............................. ...........

Permintaan Permintaan Foto Roentgen / USG

: .............................. ............................... ........................................ ............................. ...........

Rujuk Ke RS

: .............................. ............................................................ ............................. ............................... ...........

: ....................

Gresik, ........................................... Tanda Tangan Dokter

.......................................................

Hasil Pembacaan radiologi / USG

.............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. .............................................................................................................................................................................. Tanda Tangan Dokter

..................................................