Name : Aisya Syifa Azzahra

Number : 01

Class : XII IPS 2

Find 3 different types of form (pictures) then tell content of each forms!

1. Medical form

Form above is medical form, exactly is “New Patient Registration Form”

The content is :
1. Date
2. Patient information, include : 1) Name 6) Addres
2) Marital Status 7) Social Security no
3) Birth date 8) Home phone / cell phone no
4) Age 9) Occupation
5) Sex 10) Employer & employer no
3. Insurance information, include : 1) Identity patient covered by insurance
2) Person responsible for bill
3) Identity of subscriber
4) Patient’s relationship to subscriber
4. 4. In case of emergency, include : 1) Name of local friend or relative
2) Relationship to patient
3) Home phone no
4) Work phone no
2. Reservation form
The form beside is reservation form, exactly is “
International Student Exchange Application Form”
The content is :
1. Full name 9. Birth date 17. Country
2. First name 10. Birth year 18. Neighborhood
3. Last name 11. Place of birth 19. Address
4. Nick name 12. Age 20. Phone
5. Gender 13. Hometown 21. Mobile
6. Sex 14. City 22. Fax/email
7. Marital status 15. State/Region 23. School
8. Nationality 16. Postal code 24. Year graduated
3. Withdrawal Slip

The form above is withdrawal slip, exactly is “Savings Withdrawal”

The content is : 1. Date

2. Your account number

3. Your name

4. Your signature

5. Total amount you want to save