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FORMULIR PENDAFTARAN

MINANG MEDICAL CENTER


JL.A. Yani No.1-B Padang Sumatera Barat

Telp. (0751) 895 1172

No.RM : Ruang/Kelas : ...............................................................

TGL Masuk : ............................................ Jam Masuk : ................................... WIB Sr/Pg/Ml

Kiriman dari : .....................................................

Nama Lengkap : ..................................................... Jenis Kelamin :

Alamat : ..................................................... No. Telp : .........................................

Umur/Tgl Lahir : ...............Th/.................................

Agama : .....................................................

Nama Penanggung Jawab :

Hubungan Keluarga :

Alamat Lengkap :

Pekerjaan :

Tanggal, ...........................
Administrasi

.....................................
Nama Jelas/Teran

FORMULIR PENDAFTARAN
MINANG MEDICAL CENTER
JL.A. Yani No.1-B Padang Sumatera Barat

Telp. (0751) 895 1172

No.RM : Ruang/Kelas : ...............................................................

TGL Masuk : ............................................ Jam Masuk : ................................... WIB Sr/Pg/Ml

Kiriman dari : .....................................................

Nama Lengkap : ..................................................... Jenis Kelamin :

Alamat : ..................................................... No. Telp/Hp : .........................................

Umur/Tgl Lahir : ...............Th/.................................

Agama : .....................................................
Nama Penanggung Jawab :

Hubungan Keluarga :

Alamat Lengkap :

Pekerjaan :

Tanggal, ...........................
Administrasi

.....................................
Nama Jelas/Teran
.........................................

............. WIB Sr/Pg/Ml

L/P

.............................................

Tanggal, ....................................
Administrasi

...............................................
Nama Jelas/Terang

.........................................

............. WIB Sr/Pg/Ml

L/P

.............................................
Tanggal, ..................................
Administrasi

...............................................
Nama Jelas/Terang