Form Pendaftaran
Royal Premier
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Nama Lengkap
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Gender
*
Laki-laki
Perempuan
Tanggal Lahir
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MM slash DD slash YYYY
No Kepesertaan BPJS
Dokter yang sering di kunjungi
No Telpon
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status
Menunggu Pembayaran
Sudah Dibayar
Kedaluwarsa
Gagal
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payment_channel
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external_id
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amount
