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New patient registered
2 minutes ago
Patient data updated successfully.
10 minutes ago
J
John Doe
johndoe@email.com
Administrator
Doctor
Nurse
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Patient Registration Form
Patient Type
*
General (Cash & Guarantee)
Inhealth
Patient Profile
Search Existing Patient
Prefix/Title
Full Name
*
Suffix
Place of Birth
Date of Birth
*
Gender
*
Male
Female
Ethnicity
Religion
Select religion
Islam
Christian
Catholic
Hindu
Buddhist
Confucian
Other
Belief
National ID Number
*
Must be exactly 16 digits
Other ID (Passport)
Mobile Number
*
+62
+60
+65
Phone Number
Fax
Education Level
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None
Primary
Secondary
Diploma
Bachelor
Master
Doctorate
Email
Marital Status
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Single
Married
Divorced
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Family Relationship
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Father
Mother
Sibling
Spouse
Child
Other
Blood Type
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A
B
AB
O
Economic Status
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Low
Middle
High
Nationality
Select nationality
Indonesian
Foreign
Organization
Domicile
Address
Sub-district
District
Regency/City
Province
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DKI Jakarta
West Java
Central Java
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Bali
Postal Code
Allergy
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Allergy
Allergy Type
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None
Food
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Pollen
Medicine
Other
Reaction
Severity Level
Side Effect
Incident Date
Family Data
Add Family Member
Please pay attention to spelling and capitalization when filling in, because once saved, the name input cannot be edited.
Name
Type
Select allergy type
None
Text
Other
Gender
*
Male
Female
Place of Birth
Date of Birth
Family Data
Select
Yes
No
Mobile Number
Family Relationship
Select relationship
Father
Mother
Sibling
Spouse
Child
Other
Job Title
Company Name
Company Address
