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Nama Lengkap (Full Name)
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Nomor KTP (ID Card Number)
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Unggah KTP (Upload ID Card)
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Max size 2.5MB
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Whatsapp
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08xxxxxxxxxxx
Email
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xxxxxx@xxxxx.xxx
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Tempat Lahir (Place of Birth)
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Tanggal Lahir (Date of Birth)
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Jenis Kelamin (Gender)
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Laki-laki / Male
Perempuan / Female
Golongan Darah (Blood Type)
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Pilih/Select
A positive (A+).
A negative (A-).
B positive (B+).
B negative (B-).
AB positive (AB+).
AB negative (AB-).
O positive (O+).
O negative (O-)
Agama (Religion)
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Pilih/Select
Islam / Moslem
Katolik / Catholic
Kristen / Christian
Budha / Buddhist
Kong Hu Chu
Hindu
Status Perkawinan (Marriage Status)
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Pilih/Select
Lajang / Single
Menikah / Married
Bercerai / Divorce
Alamat Domisili (Residence Address)
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Pekerjaan (Occupation)
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Riwayat Penyakit (Disease History)
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Ada Riwayat (Yes)
Tidak Ada (No)
Rinci Riwayat Penyakit (Detailed Disease History)
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Warga Negara (Nationality)
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Pilih/Select
WNI
WNA (Foreigners)
Negara Asal (Country of Origin)
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Penangung Jawab Pembayaran (Responsible for Payment)
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Pribadi (Personal)
Rinci Penanggung Jawab Pembayaran (Responsible for Payment)
Darimana anda tahu tentang kami? (How do you know about us?)
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Website
Instagram
Youtube
Event
Brosur (Brochure)
Teman (Friends)
Kerabat (Relatives)
Dokter / Rumah Sakit (Referral)
Seminar (Health Talk)
Lainnya (Other)
Nama Dokter / Rumah Sakit (Referral)
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Nama Teman/Kerabat (Name of Friend/Relative)
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Event (Health Talk)
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Lainnya (Other)
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