drg.
Noryunita Rahmah
SIP : B.009/DPMPTSP/503-SIP-D-IX/2021
Jl. A. Yani no. 042, RT. 002, Kelurahan Pulau, Kecamatan Kelua, Tabalong
SURAT RUJUKAN RONTGEN
Kepada :
................................................
................................................
Dengan hormat, mohon dilakukan rontgen :
Jenis X-Ray Photo
o Panoramic / OPG o Cephalometri o PA Skull
o Lateral o Periapical o Oklusal
o Shift Scatch o Periapical CR o TMJ
Regio
Dewasa
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Anak-anak
V IV III II I I II III IV V
V IV III II I I II III IV V
Nama : ............................................................................................................
Usia : ............................................................................................................
Alamat : ............................................................................................................
Diagnosa : ............................................................................................................
Tabalong,
drg. Noryunita Rahmah