BookingDokter New Medical Facility Affiliate Registration
Formulir Pendaftaran untuk Fasilitas Medis Calon Afiliasi BookingDokter
Email address *
Nama Fasilitas Medis: *
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Lokasi (Nama Gedung & Nama Jalan): *
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Kota/Kabupaten: *
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Propinsi: *
Kode Pos: *
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No. Telepon (untuk lokasi yang didaftarkan): - termasuk nomor kode area, contoh +62 21 *
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No. HP (Whatsapp) Customer Service (untuk lokasi yang didaftarkan): - termasuk nomor kode area, contoh +62 ...
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Website:
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Jam Operasional (Hari dan Jam): *
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Nama yang Mereferensikan: (jika ada)
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A copy of your responses will be emailed to the address you provided.
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