Form Registrasi Online Pasien Klinik Pratama BNNP NTB
No. Rekam Medik :
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NAMA IBU *
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NAMA AYAH *
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TEMPAT LAHIR *
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TANGGAL LAHIR *
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UMUR *
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JENIS KELAMIN *
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STATUS PERNIKAHAN *
PEKERJAAN *
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ALAMAT RUMAH *
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DIKIRIM OLEH *
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