FORM REGISTRASI PEMERIKSAAN RAPID TEST COVID-19
**Pastikan Data Anda Terisi Dengan Lengkap Dan Benar**
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RUMAH SAKIT UMUM SYIFA MEDIKA BANJARBARU
KEPERLUAN PEMERIKSAAN RAPID TES *
NIK *
NAMA LENGKAP (*SESUAI KTP*) *
TEMPAT LAHIR *
TANGGAL LAHIR *
MM
/
DD
/
YYYY
JENIS KELAMIN *
ALAMAT LENGKAP (*CANTUMKAN BESERTA RT/RW*) *
PEKERJAAN *
NO WHATSAPP *
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