JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Formulir Registrasi Mitra HASIM
Mohon melengkapi seluruh data yang diperlukan, untuk keperluan pendataan mitra HASIM
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Nama Fasilitas Kesehatan
*
Your answer
Jenis Fasilitas Kesehatan
*
Praktek Dokter Pribadi
Klinik
Rumah Sehat
Balai Kesehatan Masyarakat
Other:
Data Poli di Fasilitas Kesehatan
Poli Umum
Poli Gigi
Poli Fisioterapi
Poli Kecantikan
Other:
Apakah Fasilitas Kesehatan Memiliki Gudang Obat/ Farmasi?
*
Ya
Tidak
Alamat Fasilitas Kesehatan
*
Your answer
Nomor Handphone/ Whatsapp
*
Your answer
Nama Pemilik Fasilitas Kesehatan
*
Your answer
Jumlah Staff di Fasilitas Kesehatan
*
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
