FORM PENDAFTARAN PASIEN BARU

(PATIENT IDENTITY)
The Bellagio Mansion Unit G-02, Ground Floor
Jl. Lingkar Mega Kuningan Blok E6 No. 1
Kuningan Timur - Jakarta Selatan

ANAK (CHILD)
Nama Lengkap(Full Name) :
Tempat/TanggalLahir(Place/DateofBirth):
JenisKelamin(Gender) :L/P(Male/Female)
Agama(Religion) :
GolDarah(BloodType):
RiwayatAlergi(Allergy):
Alamat Lengkap (Address) :

No.Telepon/HP(PhoneNumber):
AlamatE-mail(E-mailAdress):
AYAH (FATHER) IBU (MOTHER)
Nama ( Name) : Nama(Name) :
Usia(Age): Usia(Age) :
No.Telp/Hp(PhoneNo.): No. Telp/Hp (Phone No.):
Pekerjaan(Occupation): Pekerjaan(Occupation):
Pendidikan terakhir (Recent Education) : Pendidikan terakhir (Recent Education) :

Agama(Religion): Agama(Religion):
Suku/Bangsa(Race/Nationality): Suku/Bangsa(Race/Nationality):
PENANGGUNG JAWAB (PERSON IN CHARGE)
Nama(Name) :
Hub.DenganPasien(RelationtoPatient) :
AlamatLengkap(Address) :

No.Telepon/HP(PhoneNumber) :
Pekerjaan(Occupation) :
MetodePembayaran(Payment) :
PoliTujuan/ Selected Policlinic
1. dr.SpesialisAnak(Pediatrician) 3.Psikolog(Psychologist) 5. Laboratorium(Laboratory)
2. dr.Umum(GeneralPractitioner) 4.AhliGizi(Dietician) 6. Radiologi(Radiology)
7. ..........................................

Jakarta, 8 April 2021

PetugasPendaftaran Pasien/ WaliPasien
Registration Officer Patient/PersonInCharge

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