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Reservation Wellness Special
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Nama Lengkap Karyawan
Employee Full Name
*
Your answer
Nama Perusahaan
Company Name
*
Contoh : PT. GWS Era Medika
Your answer
Jenis Pelayanan 25 Juli 2023
Type of Service 25 July 2023
Influenza Vaccination
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Jenis Pelayanan 28 Juli 2023
Type of Service 28 July 2023
Immune Booster
Glow Therapy
Instant Detox
Dengue Vaccination
HPV-9 Vaccination
Vitamin B 5000 Injection
Vitamin C 1000 Injection
HPV-4 Vaccination
Apakah Anda pernah melakukan treatment ini sebelumnya?
*
Have you ever had this treatment before?
Yes
No
Apakah Anda pernah merasakan adanya efek samping setelah mendapatkan treatment tersebut?
Have you ever experienced any side effects after getting that treatment?
Your answer
Apakah ada obat-obatan yang sedang Anda konsumsi secara rutin saat ini? Sebutkan
*
Are there any medications you are currently taking regularly? Please specify
Your answer
Apakah Anda memiliki riwayat penyakit?
Do you have any medical history?
*
Contoh : Ya, diabetes/darah tinggi
Your answer
Available Time
*
Pilihlah waktu yang available untuk anda, kami akan mengirimkan konfirmasi setelah melakukan pengisian form ini.
Batch 1 (10.00-10.30)
Batch 2 (10.30 - 11.00)
Batch 3 (11.00 - 11.30)
Batch 4 (11.30 - 12.00)
Batch 5 (13.30 - 14.00)
Batch 6 (14.00 - 14.30)
Batch 7 (14.30 - 15.00)
Batch 8 (15.00 - 15.30)
Batch 9 (15.30 - 16.00)
Batch 10 (16.00 - 16.30)
Batch 11 (16.00 - 17.00)
Batch 12 (17.00 - 17.30)
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