Jl. Prof. H.M. Yamin No.

17 Tebing Tinggi
Telepon : (0621) 3950222
Fax : (0621) 3950221
Email : rschevani175@gmail.com

BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

Nama : BPJS
No. RM : Perusahaan
Klinis/Diagnosa : Umum
Ruang/Poli :

PEMERIKSAAN RONTGEN

MANUS L/R LUMBAL AP/LAT

WRIST JOINT L/R PELVIC
ANTEBRACHI L/R DENTAL
ELBOW JOINT L/R THORAX PA/AP
HUMERUS L/R BNO
SHOULDER JOINT L/R POLOS ABDOMEN
CRURIS L/R CLAVICULA L/R
ANGKLE JOINT L/R HIP JOINT L/R
PEDIS L/R FEMUR L/R
SCHEDEL L/R KNEE JOINT L/R
MASTOID L/R CALCANEUS
SPN WATER/LAT BNO IVP
MANDIBULLA APPENDICOGRAM
TMJ L/R HSG
NASAL OESOPHAGUS
CERVICAL AP/LAT COLON IN LOOP
THORACAL AP/LAT ………………………

Ket: L = Kiri
R = Kanan
Tebing Tinggi, ………………….. 20……
Dokter Pengirim
 Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi
Telepon : (0621) 3950222
Fax : (0621) 3950221
Email : rschevani175@gmail.com

BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

Nama : BPJS
No. RM : Perusahaan
Klinis/Diagnosa : Umum
Ruang/Poli :

PEMERIKSAAN USG

USG UPPER ABDOMEN USG SOFT TISSUE

USG LOWER ANDOMEN USG PROSTAT
USG UPPER + LOWER ABDOMEN USG THYROID
USG THORAX USG MAMAE
USG EXTREMITAS USG TESTIS
USG SOFT TISSUE USG APPENDIX
USG EXTREMITAS ………………………..

Tebing Tinggi, ………………….. 20……

Dokter Pengirim
 Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi
Telepon : (0621) 3950222
Fax : (0621) 3950221
Email : rschevani175@gmail.com

BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

Nama : BPJS
No. RM : Perusahaan
Klinis/Diagnosa : Umum
Ruang/Poli :

PEMERIKSAAN CT SCAN

CT SCAN KEPALA C/NC CT SCAN SPINE CERVICAL C/NC

CT SCAN ORBITA C/NC CT SCAN SPINE THORACAL C/NC
CT SCAN SELLA TURSICA C/NC CT SCAN SPINE LUMBAL C/NC
CT SCAN MANDIBULLA C/NC CT SCAN MAXILLA C/NC
CT SCAN NASOPHARINX C/NC CT SCAN LARYNX C/NC
CT SCAN EXTREMITAS ATAS C/NC CT SCAN THORAX C/NC
CT SCAN EXTREMITAS BAWAH C/NC CT SCAN PELVIS C/NC
CT SCAN UPPER ABDOMEN C/NC CT SCAN SPN C/NC
CT SCAN LOWER ABDOMEN C/NC CT SCAN FACIAL BONE C/NC
CT SCAN ABDOMEN UPP/LOW C/NC ………………………………..
CT SCAN CONE BEAM DENTAL C/NC ………………………………..

Ket: C = Kontras
NC = Non Kontras
Tebing Tinggi, ………………….. 20……
Dokter Pengirim
 Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi
Telepon : (0621) 3950222
Fax : (0621) 3950221
Email : rschevani175@gmail.com

BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

Nama : BPJS
No. RM : Perusahaan
Klinis/Diagnosa : Umum
Ruang/Poli :

PEMERIKSAAN LABORATORIUM

DARAH RUTIN URINE ANALYSA FUNGSI HATI

Haemoglobine Urine Rutin SGOT
Leucocyte Test Kehamilan SGPT
Eritrocyt Beta HCG Serum Alkali Pospatase
Thrombocyt Bilirubin Total Direct
Hematocryt PROFILE TIROIT Albumin/GL
MCV, MCH, MCHC T3 Globulin
T4 Protein Total
FUNGSI GINJAL TSH HBe Antigen
Ureum Anti HBs
Creatinin LIPID PROFILE Anti HCV
Urid Acid Cholesterol Total IgG Anti HAV
HDL Cholesterol IgM Anti HAV
TEST KOAGULASI LDL Cholesterol Anti HBe
Masa Perdarahan Trigleserida HBs Ag
Masa Pembekuan
ELEKTROLIT
PARASIT DARAH Natrium
Malaria Kalium
Micro Filaria Clorida

Tebing Tinggi, ………………….. 20……

Dokter Pengirim