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FORM PENDAFTARAN ONLINE VAKSINASI COVID-19 DOSIS 3 (BOOSTER)
DINAS KESEHATAN KABUPATEN BARITO TIMUR
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Email
*
Your email
NAMA LENGKAP (Sesuai KTP)
*
Your answer
NIK KTP (Nomor Induk Kependudukan)
*
Your answer
Tanggal Lahir
*
MM
/
DD
/
YYYY
Usia/Umur
*
Your answer
Alamat Lengkap Sesuai KTP
*
Your answer
Alamat Domisili (Diisi jika berbeda dengan alamat KTP)
Your answer
No. Handphone (Untuk menerima sertifikat Vaksin Peduli Lindungi)
*
Your answer
Jenis Vaksin Dosis 1
*
Coronavac/Sinovac
Moderna
AstraZeneca
Pfizer
Janssen (J&J)
Sinopharm
Other:
Required
Jenis Vaksin Dosis 2
*
Coronavac/Sinovac
Moderna
AstraZeneca
Pfizer
Janssen (J&J)
Sinopharm
Required
TANGGAL VAKSIN DOSIS 2
*
MM
/
DD
/
YYYY
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Jerry Aprilianto, A.Md.KL (0821 5316 4874)
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