warungasem.simpus.dinkes.batangkab.go.id Open in urlscan Pro
103.107.245.253  Public Scan

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1 forms found in the DOM

POST /daftar

<form action="/daftar" method="post" id="formDaftar" novalidate="true">
  <h4 class="text-2xl font-semibold">Pendaftaran Pasien</h4>
  <p class="leading-relaxed mt-1 mb-4 text-gray-600"> Lengkapi formulir ini dan kami akan menghubungi Anda dalam 24 jam. </p>
  <div class="relative w-full mb-3 mt-8">
    <label class="block uppercase text-gray-700 text-xs font-bold mb-2" for="full-name">Poliklinik</label>
    <select name="poliklinik" id="poliList" class="border-0 px-3 py-3 placeholder-gray-400 text-gray-700 bg-white rounded text-sm shadow focus:outline-none focus:ring w-full" required="">
    </select>
  </div>
  <div class="relative w-full mb-3">
    <label class="block uppercase text-gray-700 text-xs font-bold mb-2" for="full-name">Dokter Praktek</label>
    <select name="dokter" id="dokterList" class="border-0 px-3 py-3 placeholder-gray-400 text-gray-700 bg-white rounded text-sm shadow focus:outline-none focus:ring w-full" required="">
      <option></option>
    </select>
  </div>
  <div class="relative w-full mb-3">
    <label class="block uppercase text-gray-700 text-xs font-bold mb-2" for="full-name">Tanggal Periksa</label>
    <input datepicker="" datepicker-autohide="" datepicker-buttons="" datepicker-autoselect-today="" datepicker-format="dd-mm-yyyy" name="tanggal" id="default-datepicker" type="text"
      class="bg-gray-50 border border-gray-300 text-gray-900 text-sm rounded-lg focus:ring-blue-500 focus:border-blue-500 block w-full ps-10 p-2.5 dark:bg-gray-700 dark:border-gray-600 dark:placeholder-gray-400 dark:text-white dark:focus:ring-blue-500 dark:focus:border-blue-500"
      placeholder="Tanggal Periksa" required="">
  </div>
  <div class="relative w-full mb-3">
    <label class="block uppercase text-gray-700 text-xs font-bold mb-2" for="full-name">No Nik</label><input type="text" name="nik"
      class="border-0 px-3 py-3 placeholder-gray-400 text-gray-700 bg-white rounded text-sm shadow focus:outline-none focus:ring w-full" placeholder="Nik" style="transition: all 0.15s ease 0s;" required="" minlength="16" maxlength="16">
  </div>
  <div class="relative w-full mb-3">
    <label class="block uppercase text-gray-700 text-xs font-bold mb-2" for="email">Nama Lengkap</label><input type="text" name="nama"
      class="border-0 px-3 py-3 placeholder-gray-400 text-gray-700 bg-white rounded text-sm shadow focus:outline-none focus:ring w-full" placeholder="Nama Lengkap" style="transition: all 0.15s ease 0s;" required="">
  </div>
  <div class="relative w-full mb-3">
    <label class="block uppercase text-gray-700 text-xs font-bold mb-2" for="email">No Bpjs</label><input type="text" name="bpjs"
      class="border-0 px-3 py-3 placeholder-gray-400 text-gray-700 bg-white rounded text-sm shadow focus:outline-none focus:ring w-full" placeholder="No Bpjs" style="transition: all 0.15s ease 0s;">
  </div>
  <div class="relative w-full mb-3" id="svgdata"><svg xmlns="http://www.w3.org/2000/svg" width="150" height="50" viewBox="0,0,150,50">
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    </svg></div>
  <div class="relative w-full mb-3">
    <label class="block uppercase text-gray-700 text-xs font-bold mb-2" for="full-name">Captcha</label>
    <input type="text" name="captcha" class="border-0 px-3 py-3 placeholder-gray-400 text-gray-700 bg-white rounded text-sm shadow focus:outline-none focus:ring w-full" placeholder="Captcha" style="transition: all 0.15s ease 0s;" required="">
  </div>
  <div class="text-center mt-6">
    <button class="bg-gray-900 text-white active:bg-gray-700 text-sm font-bold uppercase px-6 py-3 rounded shadow hover:shadow-lg outline-none focus:outline-none mr-1 mb-1" type="submit" style="transition: all 0.15s ease 0s;"> Kirim antrian </button>
  </div>
  <input type="hidden" name="captchaid" value="1732108027549">
</form>

Text Content

PUSKESMAS WARUNGASEM

Pendaftaran Online

PENDAFTARAN PASIEN

Lengkapi formulir ini dan kami akan menghubungi Anda dalam 24 jam.

Poliklinik
Dokter Praktek
Tanggal Periksa
No Nik
Nama Lengkap
No Bpjs

Captcha
Kirim antrian