Form Pencatatan Pelaksanaan Vaksinasi Covid-19  dari jam 10.00 s/d jam 12.30 (DIHARAPKAN MEMBAWA PULPEN DAN FC KTP)
RSD IDAMAN KOTA BANJARBARU
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KTP *
NAMA LENGKAP *
jenis kelamin *
Pekerjaan *
Tgl lahir *
MM
/
DD
/
YYYY
Alamat KTP *
nomor HP *
tanggal vaksin pertama ( boleh di kosongkan apa bila belum vaksin )
MM
/
DD
/
YYYY
tanggal vaksin ke dua ( boleh di kosongkan apa bila belum vaksin )
MM
/
DD
/
YYYY
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