Nama : Siti Qomarun Anisa Fitri

Kelas : 2A

NIM : P1337420419079

Mata Kuliah : Bahasa Inggris

REGISTRATION FORM PATIENT

1. Patient Name*

2. Nick Name Patient*

3. AGE*

4. Gender*

5. History of disease*

6. NO medical records*

7. NO KTP*

8. No family card
9. NO BPJS

10. Family relationship*

11. Date of birth*

12. Address Patient*

13. Religion Patient*

14. Status Patient*

15. Blood Group*

16. Profession Patient*

o Wiraswasta
o PNS
o Teacher
o Laborer
o Farmer
o Other
17. Work income*
o < 1.000.000
o 1.000.000 - 5.000.000
o 6.000.000 – 10.000.000
o > 10.000.000

SIGNATURE

(PERSON IN CHANGE)