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    Receiving Form

    Uploaded by

    reactive.medical

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Receiving Form

    Uploaded by

    reactive.medical
    1 views1 page

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1 views1 page

    Receiving Form

    Uploaded by

    reactive.medical

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    REACTIVE MEDICAL

    LABORATORY AND X-RAY


    (RECEIVING)

    CONTROL #: _____________________ DATE: ________________________

    NAME: ______________________________________________________________
    (FAMILY NAME) (FIRST NAME) (M.I)

    AGE: ______ SEX: ___________ DATE OF BIRTH: __________________

    ______________________________________________________________________
    NAME OF COMPANY / NAME OF SCHOOL

    EXAMINATION DESIRED

    ___________ Chest X-Ray / PA


    ___________ Complete Blood Count (CBC)
    ___________ Urinalysis (U/A)
    ___________ Stool Examination / Fecalysis (S/E)
    ___________ Pregnancy Test (PT)
    ___________ HBsAg (HEPA B)
    ___________ DRUGTEST
    ___________ HEPA A
    ___________ BLOOD TYPING
    ___________ VDRL / RPR / SYPHILIS
    ___________ HIV
    ___________ PHYSICAL EXAM
    ___________ ECG

    OTHERS: ___________________________________________________

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