Form Permintaan Pemeriksaan Laboratorium

Lampiran

RUMAH SAKIT KHUSUS IBU DAN ANAK

WIJAYAKUSUMA

2RMINTAAN 2M2RIKSAAN 3AB4RAT4RIUM

Jl. Gelatik No.1 Kebumen 5!1" Ja#a Ten$a% Tel&'(a). * +,"-/ !-105

Nama Lengkap

: …………………………………………………………………….. L/P

Umur Ruang

: ……………………………………………………………………… :……………………………………………………………………….

H E M AT O L O G I

FAA L H ATI

 Hematologi Lengkap (Hb,  "ilirubin Total

AL, AT, HT, Eri, Di!

I NF E K SI L AI N

 #i$al te%t

 "ilirubin Direk

 &g' / &g T)p*oi$

 Hemoglobin (Hb!

 Protein Total

 &g'/ &g Dengue

 Leuko%it (AL!

 Albumin

 N+

 gTrombo%it (AT!

 lobulin

 T&R-&D

 Hematokrit (HT!

 +-T

 T+H% (T+H!

 Eritro%it (Eri!

 +PT

 reeT0

 Hitung

1eni%

 ree T

Leuko%it PROFIL LEMAK

(Di!

 2ole%terol Total3 ALERGI

 LED / ""+

 2ole%terol HDL

 olongan Dara*

 2ole%terol LDL3

 'alaria

 Trigli%eri$a3

 Te% Alergi

LAIN-LAIN

 'orologi

Dara*

 R*eumatoi$ a4tor  A+T-

Tepi IMMUNO-SEROLOGI

('DT!

 5RP HEPATITIS

HEMOSTASIS

 H"%Ag PENANDA TUMOR

 'a%a Pembekuan (5T!

 PA / *i%topatologi 6aringan TORCH

 'a%a Per$ara*an ("T!

 &g Anti To7opla%ma

KIMIA DARAH

 &g' Anti To7opla%ma

DIABETES

 A8i$ita% &g To7opla%ma  Urine Rutin

URINALISIS

 luko%a Dara* +e9aktu

(D+!  luko%a

 &g' Anti Rubella ANALISA FAESES

 &g Anti Rubella

Dara*

(DP! 3  luko%a ; 1am PP

 PAP +'EAR

Pua%a

 ae%e% Rutin

 &g' Anti 5' CAIRAN TUBUH

 &g Anti 5'  A8i$ita% &g' 5'

 Anali%a L5+ FERTILITAS

Lampiran

 &g' Anti H+ 

 Te% 2e*amilan

FAAL GINJAL

 Ureum

 &g Anti H+ 

 2reatinin

 &g' Anti H+ ;

 'ata

 A%am Urat 3

 &g Anti H+ ;

 agina / Uretra

SEKRET

 +putum ("TA!

Pemerik%aan lain )ang $iminta : 2et : 3 Pua%a < = ; 6am %ebelumn)a

Dokter Yang Meminta

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