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Pondok Indah Medical Centre - Antigen Swab Registration Form
영어로 작성 부탁드립니다. (한국어 입력시 오류 발생)
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* Indicates required question
Identity Card
*
KTP/Resident ID Card
PASPOR/PASSPORT
Identity Number (KTP/PASSPORT)
*
Please provide your valid ID number as requirement from Kemenkes (Ministry of Health) / Kemenkes (보건부)의 요구 사항으로 유효한 ID 번호를 제공하십시오 / 여권 번호를 알려주세요)
Your answer
Nama Lengkap/Full Name/영문 성함
*
Your answer
Tempat Lahir/Place of Birth/출생지 (국가)
*
Your answer
Tanggal Lahir/Date of Birth/생년월일
*
MM
/
DD
/
YYYY
Jenis Kelamin/Sex/성별
*
Laki-laki/Male/남성
Perempuan/Female/여성
Kebangsaan/Nationality/국적
*
Your answer
Alamat Lengkap/Address/주소 (ID Card/KITAS/Passport)/
*
Your answer
Alamat Tinggal Saat Ini/Current Residential Address/자카르타 현지 주소
*
Your answer
Nomor Telepon/Phone Number/핸드폰 번호
*
Your answer
Alamat E-Mail/E-Mail Address/이메일
*
Your answer
Cara Pembayaran/Payment Method/결제 방법
*
Tunai/Cash/현금
Debit/Credit Card(체크/신용 카드)
Other:
Jaminan Pembayaran/Payment Guarantee/지급 보증
*
Umum/Self Payment( 개인)
Insurance (보험)
Other:
Pelayanan/Service/검사 방법
*
Antigen
Tanggal Reservasi/Reservation Date/예약일
*
MM
/
DD
/
YYYY
Waktu Reservasi/Reservation Time/예약 시간
*
24 Hour Format
Time
:
AM
PM
Jenis Pelayanan/Type of Service/검사 방법
*
Walk-in
Drive-thru
Home Visit
Company Visit
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