F-02-PG-4.4,Ed. 2/Rev.

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4000348 Cluj-Napoca, str. Iuliu Moldovan 23
Tel.: 0264-594.655, Fax: 0264-593.105
E-mail: infectioasecj@yahoo.com
Laboratorul de analize medicale
E-mail: labinfecluj@yahoo.com
CERERE DE ANALIZE MEDICALE

Numele si prenumele pacientului:....................................................

CNP:..................................................................................................... Cod Set:
Nr.telefon de contact......................................................................... :
Trimis de: Spital:…………………………………………………………
Doctor..............................................................................
Diagnostic prezumtiv.......................................................................................................................
Tip proba /Loc anatomic de prelevare …………………………………………………………………
Data/ora recoltarii probei primare …………………………………..................................................

Analize solicitate: ………………………………………………………………………………………..

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Observatii:………………………………………………………………………………………………….

Data/ora primirii in laborator ………..........................................................................................

Rezultatele vor fi ridicate:□ personal

□ de catre……………………………

Data:………………… Semnatura: