Tanggal Bulan Tahun

02 08 21

No Nama (max 33 huruf) Jenis Kelamin DOB (DMY) Umur

1 A.A. Gde Rai Madya Utama Male 8-Oct-86 34
2 I Komang Gede Sarjana Male 31-May-87 34
3 A.A. Gede Oka Metrawan Male 16-Jun-78 43
4 Rahanudin Male 31-Dec-77 43
5 Ni Nengah Muliawati Female 15-May-94 27
6 I Gusti Ayu Manik Wahyudiani Female 22-Nov-99 21
7 A.A. Oka Dhananjaya Male 17-May-98 23
8 Nyoman Teddy Bismantara Male 5-Apr-87 34
9 I Kadek Ary Krisna Dwipayana Male 16-Jul-97 24
10 I Gede Agus Santiana Male 8/25/1991 29
 Cabang Lokasi
Clinic 24 Hours Ubud

Alamat No Handphone Nama Dokter Nama Perawat

Koripan Kangin, Ds. Banjarangkan, Klun 087762803213 dr. Tibu Bening Dikyawan
Ling. Besang Tengah, Klungkung 081805575200 dr. Tibu Bening Dikyawan
Banjarangkan, Klungkung 087762784311 dr. Tibu Bening Dikyawan
Jln. Werkudara, No.12, Semarapura, Kl 081999052031 dr. Tibu Bening Dikyawan
Selisihan, Klungkung 083115136865 dr. Tibu Bening Dikyawan
Muncan, Selat, Karangasem 087701385419 dr. Tibu Bening Dikyawan
Jln. Gunung Rinjani 5, Semarapura kangi 089638343506 dr. Tibu Bening Dikyawan
Jln. Gg Muria IB No.15 081529123774 dr. Tibu Bening Dikyawan
Br. Dinas Belong, Manggis 082144704591 dr. Tibu Bening Dikyawan
Br. Kutampi Kaler Nusapenida 085829253369 dr. Tibu Bening Dikyawan
Nama Analis Tgl Sampling DMY Lab Order Patient ID Tgl Print DMY Hasil Test
Dikyawan ### 11 21080211 ### Negative
Dikyawan ### 12 21080212 ### Negative
Dikyawan ### 13 21080213 ### Negative
Dikyawan ### 14 21080214 ### Negative
Dikyawan ### 15 21080215 ### Negative
Dikyawan ### 16 21080216 ### Negative
Dikyawan ### 17 21080217 ### Negative
Dikyawan ### 18 21080218 ### Negative
Dikyawan ### 19 21080219 ### Negative
Dikyawan ### 20 21080220 ### Negative
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 11 Patient ID : 21080211

Name : A.A. Gde Rai Madya Utama Company : UbudCare Clinic 24 Hours
Date of Birth : 10/8/1986 (34 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Koripan Kangin, Ds. Banjarangkan, Klungkung

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 12 Patient ID : 21080212

Name : I Komang Gede Sarjana Company : UbudCare Clinic 24 Hours
Date of Birth : 5/31/1987 (34 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Ling. Besang Tengah, Klungkung

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
dobel klik dua kali dimana saja untuk memunculkan
nama di sheet
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 13 Patient ID : 21080213

Name : A.A. Gede Oka Metrawan Company : UbudCare Clinic 24 Hours
Date of Birth : 6/16/1978 (43 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Banjarangkan, Klungkung

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
dobel klik dua kali dimana saja untuk memunculkan
nama di sheet
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 14 Patient ID : 21080214

Name : Rahanudin Company : UbudCare Clinic 24 Hours
Date of Birth : 12/31/1977 (43 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Jln. Werkudara, No.12, Semarapura, Klungkung

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized : Dikyawan

Catatan Khusus :
dobel klik dua kali dimana saja untuk memunculkan
nama di sheet
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 15 Patient ID : 21080215

Name : Ni Nengah Muliawati Company : UbudCare Clinic 24 Hours
Date of Birth : 5/15/1994 (27 y.o.) Doctor : dr. Tibu Bening
Gender : Female
Drawn date : 8/2/2021
Address : Selisihan, Klungkung

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
dobel klik dua kali dimana saja untuk memunculkan
nama di sheet
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 16 Patient ID : 21080216

Name : I Gusti Ayu Manik Wahyudiani Company : UbudCare Clinic 24 Hours
Date of Birth : 11/22/1999 (21 y.o.) Doctor : dr. Tibu Bening
Gender : Female
Drawn date : 8/2/2021
Address : Muncan, Selat, Karangasem

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
amrita108
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 17 Patient ID : 21080217

Name : A.A. Oka Dhananjaya Company : UbudCare Clinic 24 Hours
Date of Birth : 5/17/1998 (23 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Jln. Gunung Rinjani 5, Semarapura kangin, KLK

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
dobel klik dua kali dimana saja untuk memunculkan
nama di sheet
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 18 Patient ID : 21080218

Name : Nyoman Teddy Bismantara Company : UbudCare Clinic 24 Hours
Date of Birth : 4/5/1987 (34 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Jln. Gg Muria IB No.15

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
dobel klik dua kali dimana saja untuk memunculkan
nama di sheet
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 19 Patient ID : 21080219

Name : I Kadek Ary Krisna Dwipayana Company : UbudCare Clinic 24 Hours
Date of Birth : 7/16/1997 (24 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Br. Dinas Belong, Manggis

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan

Catatan Khusus :
dobel klik dua kali dimana saja untuk memunculkan
nama di sheet
 CERTIFICATE OF LABORATORY EXAMINATION

Lab order no. : 20 Patient ID : 21080220

Name : I Gede Agus Santiana Company : UbudCare Clinic 24 Hours
Date of Birth : 8/25/1991 (29 y.o.) Doctor : dr. Tibu Bening
Gender : Male
Drawn date : 8/2/2021
Address : Br. Kutampi Kaler Nusapenida

Laboratory Testing Result

Analyte Result Unit Reference Range

Immunoserology

Rapid Test {} Antigen SARS-CoV-2 Negative Negative

Ubud , 8/2/2021 Authorized by : Dikyawan