Registration Form
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Nama Lengkap (Full Name)
*
Nomor KTP (ID Card Number)
*
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Unggah KTP (Upload ID Card)
Click or drag a file to this area to upload.
Max size 2.5MB
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Whatsapp
*
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)
*
Pilih/Select
Islam / Moslem
Katolik / Catholic
Kristen / Christian
Budha / Buddhist
Kong Hu Chu
Hindu
Status Perkawinan (Marriage Status)
*
Pilih/Select
Lajang / Single
Menikah / Married
Bercerai / Divorce
Alamat Domisili (Residence Address)
*
Pekerjaan (Occupation)
*
Riwayat Penyakit (Disease History)
*
Ada Riwayat (Yes)
Tidak Ada (No)
Rinci Riwayat Penyakit (Detailed Disease History)
*
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Warga Negara (Nationality)
*
Pilih/Select
WNI
WNA (Foreigners)
Negara Asal (Country of Origin)
*
Penangung Jawab Pembayaran (Responsible for Payment)
*
Pribadi (Personal)
Rinci Penanggung Jawab Pembayaran (Responsible for Payment)
Darimana anda tahu tentang kami? (How do you know about us?)
*
Website
Instagram
Youtube
Event
Brosur (Brochure)
Teman (Friends)
Kerabat (Relatives)
Dokter / Rumah Sakit (Referral)
Seminar (Health Talk)
Lainnya (Other)
Nama Dokter / Rumah Sakit (Referral)
*
Nama Teman/Kerabat (Name of Friend/Relative)
*
Event (Health Talk)
*
Lainnya (Other)
*
Submit
Quantitative Measurement of Injury Level
Comprehensive Treatment With Expert Team
Advance Technology Therapeutic Tools to Regenerate Injured Tissue
Personalized Nutrition According to The Genetic Condition
Optimizing Nutrition Intake Program to Support Your Performance
Weight Management Program Based on Body Composition Analysis
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Scan the code
Welspro Sports Clinic and Performance
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