Please fill the form to do an online registration in Wangaya Hospital
Patient Information
* Leave empty if you are general patient
* Leave empty if you are new patient
Visitation Information
Confirmation
Please ensure the data that you are submitting are correct as you will not be able to change it once it is submitted.
No. BPJS :
No. Surat Rujukan :
No. MR :
Patient Name :
Date Of Birth :
Address :
Email :
Telephone Number :
Visit Date :
Service :
Doctor :
Practice Time :
Website cannot be connected with SIMRS. Your reservation will be sent after the connection to SIMRS is restored. You don't need to make a new reservation again.