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Form Pendaftaran Pasien RS Permata Hati
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* Indicates required question
Nama Pasien
*
Your answer
Jenis Kelamin
*
Perempuan
Laki-Laki
Tanggal Lahir
*
MM
/
DD
/
YYYY
Alamat
*
Lengkap dengan RT, RW, Kel, Kec
Your answer
No Telepon
*
Your answer
No Identitas
*
E-KTP, SIM atau Paspor
Your answer
Poli Yang Dituju
*
Poliklinik Anak
Poliklinik Bedah
Poliklinik Penyakit Dalam
Poliklinik Kandungan
Poliklinik Gigi
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