Online Register Patient - RSUP Prof. dr. I.G.N.G. Ngoerah

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Phone Number *

Email *

Password *

Confirmation Password *

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* This account will be used for transactions on this website, once you are registered as a user, this data can be used for online patient registration

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Name *

Place of Birth *

Date of Birth *

Age *

Marital Status *

Gender *

Religion *

Job

Education *

Citizenship

Blood Group *

Country *

Address *

Province

City / District *

Domicile *

Post Code *

Village

Phone Number *

ID Card Owner *

Type of ID Card *

ID Card Number *

BPJS Number

Email *

Password *

Selfie with ID Card *

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