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Booking Date
Phone Number
Personal Data
Name
NIK
Gender
Choose
MALE
FEMALE
Place of Birth
Date of Birth
Age
Years
Father's Name
Address
Postal code
Place of Last Medical
Date of Last Medical
History of Disease
No
Type of Disease/Treatment
Yes
No
Description
1
Hypertension
2
Routine Treatment of Hypertension
3
Bloody Cough
4
Malaria
5
Cancer/ Tumor
6
Allergic Rhinitis
7
Allergy
8
Gastritis/Chronic Gastritis
9
Hemorrhoid
10
Hernia
11
Epilepsy
12
Surgery
13
Echolalia
14
Last Period
15
Diabetes Mellitus
16
Heart Disease
17
History of Active Life/Sport
18
Smoking
19
Bronchial Asthma
20
Current Complaint
21
Are you willing to be given The Influenza Vaccine
Statement
I am willing and do not mind providing correct information in the treatment and disease history table above and any losses resulting from incorrect information I provide will be borne by me and I am willing to accept sanctions for these losses.
I am willing and do not mind having a health examination (diagnostic physical examination, laboratory examination including HBsAg test, pregnancy test as a requirement before chest X-ray & other laboratory tests), X-ray and other diagnostic support on myself in accordance with the required criteria, either medical criteria or criteria determined by the company and following the examination procedures carried out by the Medilab Clinic.
I am willing and do not mind providing the results of my health examination to the company that recruits or where I work.
I will not sue anyone against any decision that has been made by Medilab Clinic in the form of FIT or UNFIT working in accordance with medical criteria or criteria set by the company, or the occurrence of interpretation errors that are not caused by errors in procedures and equipment/reagents used at Medilab Clinic.
I understand and comprehend my rights and obligations as a patient at the Medilab Clinic.
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