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Pesakit PHS
Demografik Pesakit PHS
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NOMBOR KAD PENGENALAN
*
Masukkan nombor kad pengenalan, tanpa "-". Contoh
490123405566
(nombor sahaja, tanpa abjad atau tanda)
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STATUS
*
Pilih mana-mana berkaitan
Choose
Permohonan Pesakit Baru
Aktif
Tidak Aktif
Pesakit Tumpang
NAMA
*
Masukkan nama seperti yang tertera pada kad pengenalan atau passport.
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NOMBOR TELEFON BIMBIT
*
Cth: 012-12345678
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ALAMAT
*
Your answer
NOMBOR TELEFON RUMAH
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EMAIL
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JANTINA
Choose
Lelaki
Perempuan
TARIKH LAHIR
*
MM
/
DD
/
YYYY
PEKERJAAN
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NAMA WARIS
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HUBUNGAN WARIS DENGAN PESAKIT
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NOMBOR TELEFON WARIS
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ALAMAT WARIS
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KOMEN
Sekiranya anda mempunyai sebarang pesanan kepada kami, sila tulis di bawah :)
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Kegunaan PHS
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