.

~DD,

RUMAH SAKIT UMUM DAERAH Dr. M. YUNUS [JANGAN DILIPAT]

BAGIAN RADIOLOGI
JL. BHAYANGKARA BENGKULU

NOMORFOTO . 9090 I ~c;b'2-0\

· ·r~r:······i···:·························
KIRIMAN : .......... 9.51
TANGGAL . 0 <p 'r7- / ~-;;._~····················
. ···················· ~---·················

. 10 , ~tcL rehciw c t7
NAMA . ·····························~---·········
. 1L{ ,\-q\.-uh
UMUR . ··········································
ALAMAT ··········································
JENISFOTO
rul "'0 m \YI I C
··········································

PERHATIAN
Setiap Foto Ulang
Foto Lama Harap Dibawa
j~,~ !"RSUD Dr.M. YUNUS
BENGKULU

PERMINTAAN PEMERIKSAAN RADIOLOGI

RSUD Dr. M. YUNUS BENGKULU

Isi Lengkap Dan Jelas

Untuk Jawaban Optimal

Nama : .. J'b.M.1.L.~.b.~.~.~ ... Jenis Kelamin : ...~.lt.-1'.:.. Umur : ............ ..

Alamat : .1L:. .T0..~~.1:t)........... Bagian .... ~.J.LQL*...... Nomor
Pekerjaan : ...................................... Rontgen tanggal ......, .. :: .. J.~.:-.. ?.£.1..5......... .
Pemeriksaan Rontge~ ~ang diminta ...... p.,..11.Q.@..'M.f:4...........................................
Data Klinik : ........1A.?,..... 3.8. ...... !.~P,f.1~: ............................................................ .

······································································································································
Hasil Laboratorium .................................................................................................... .
D<:>agnosa Sementara ................................................................................................. .

Catatan Eksposisi
KV . ........... .
mA .. ...........•
Sec I
•••••••••••••

Dokter
 A~RIKSAAN KESEHATAN PASIEN PT. ASKES RSUD Dr.M.YUNUS BENGKlJLU
DIAGNOSTIK PENUNJANG

BERSAMA INI KAMI DAPATKAN PEMERIKSAAN :

NAMA PENDERITA : ....~.~1.. .. 5J.t\~~.~ ........................ .
NAMA PEMEGANG KP. ASKES ..................................................................... ..
NOMOR KP. PT. ASKES
KEPADAT. S
DI .......................................................................
TANGGAL - I ). - ,-01 .I.
.. .....i~ ........................... ~ ............................... .

PEMERIKSAAN / PAKET ,
: .....0.......................
V\v\ f7t7I Vl-11 ~.....
1 ( ..................................................... ............ )

2. ................................ ( ·········································........................ )
3. ................................ ( ................................................................. )