FILLING OUT THE PAPER / PATIENT REGISTRATION FORM

Greetings:
 Good morning / afternoon / evening. -- good morning, etc. / GOOD NIGHT = GOOD BYE
 Welcome to >>>>>> hospital. I am ..-nick name---  SELF IDENTIFICATION
 First, I have to ask you some questions to fill out this patient registration form.

Content:
 What is your name?--> FULL NAME //// WHAT IS your last name?
 Can I have you phone number, please? / WOULD YOU TELL ME YOUR PHONE NUMBER, PLEASE. / your phone
number please.
 Do you have alternate phone number? It can be your cellphone number or your work number.
 What about your e-mail address? What is your e-mail address?
 Now, where do you live?  ADDRESS  where are you living?
 When were you born?  DATE OF BIRTH  (P) I was born …  How old are you?  age/usia  I am 19 y.o
 What is your BPJS number?
 Are you single / married / divorced / widowed?
 Where do you work?  I work at >>>>>>> I am student. / Is it full time / part-time?
 Who can I contact as emergency contact? What is her/his name? / What is her/his relation to you?
Where does she/he live? / What is her / his phone number?

Closing:
 Okay, that’s it. I think it’s enough. Thank you for your information to complete this form.
 You must bring this card if you want to see the doctor or to have medical examination next time.

DOB : Date of Birth  DDMMYY  date/month/year

 January 14th, 1997 (nineteen, ninety-seven) / 2001 (two thousand and one)
 14 January 1997
SAA : same as above