register.rspadgs.net
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URL:
https://register.rspadgs.net/
Submission: On June 16 via api from US — Scanned from DE
Submission: On June 16 via api from US — Scanned from DE
Form analysis
1 forms found in the DOMPOST
<form id="msform" method="POST" enctype="multipart/form-data" onkeypress="return event.keyCode != 13">
<div class="row" style="text-align:center; margin-bottom:1rem!important">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<img src="https://register.rspadgs.net/assets/logo.png" width="250">
</div>
</div>
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<!-- <label class="pay pertanyaan">NO. RM <b class = "require">*</b></label> -->
<input type="text" name="norm" class="form-control center" id="norm" placeholder="No. Rekam Medis / BPJS / NIK">
<input type="hidden" name="hakkelas" class="form-control center" id="hakkelas">
<input type="hidden" name="norm2" class="form-control center" id="norm2">
<input type="hidden" name="postranap" class="form-control center" id="postranap">
<input type="hidden" name="poliRujukan" class="form-control center" id="poliRujukan">
<input type="hidden" name="noTelpon" class="form-control center" id="noTelpon">
<!-- <input type="text" class="datepicker" required="" id="datepicker" /> -->
</div>
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<input type="button" name="cekrm" id="cekrm" value="Verifikasi" class="next verifikasi-button btn btn-md btn-success cekrm">
</div>
</div>
<div id="container_datapasien" style="display:none">
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12 labelpasien">
<label>Data Pasien</label>
</div>
<div class="col-12 col-sm-12 col-md-12 col-lg-12 labelpasien">
<strong><label id="p_namapasien"></label></strong>
</div>
<div class="col-12 col-sm-12 col-md-12 col-lg-12 labelpasien">
<label id="p_jkpasien"></label>
</div>
<div class="col-12 col-sm-12 col-md-12 col-lg-12 labelpasien">
<label id="p_alamatpasien"></label>
</div>
</div>
<div class="row" style="margin-top:10px;margin-bottom:10px">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<div style="background:#CCC; height:1px;"></div>
</div>
</div>
<div class="row" style="margin-bottom:30px;">
<div class="col-6 col-sm-6 col-md-6 col-lg-6 labelpasien">
<label>No. Rekam Medis</label>
</div>
<div class="col-6 col-sm-6 col-md-6 col-lg-6 labelpasien">
<label>No. BPJS</label>
</div>
<div class="col-6 col-sm-6 col-md-6 col-lg-6 labelpasien">
<label id="p_normpasien"></label>
</div>
<div class="col-6 col-sm-6 col-md-6 col-lg-6 labelpasien">
<label id="p_nobpjspasien"></label>
</div>
</div>
</div>
<!-- <div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan">TANGGAL LAHIR <b class = "require">*</b></label>
<input type = "date" name = "tgl_lahir" class="form-control" id = "tgl_lahir">
<input type="button" name="cekrm" id="cekrm" value="Verifikasi Data" class="next verifikasi-button cekrm" style = "float:right; width:123px;" />
</div>
</div> -->
<div class="row" style="text-align:center; display:none" id="div-table">
<!-- <div class="col-6" style="background:red"><a href = "#" id = "history">History</a></div>
<div class="col-6" style="background:red"><a href = "#" id = "daftar">Daftar</a></div> -->
<div class="col-12" style="text-align:right; margin-top:10px;">
<a href="#" class="tombol" id="history" style="text-decoration:none">RIWAYAT</a>
<a href="#" class="tombol" id="daftar" style="text-decoration:none; display:none;background: rgb(213, 160, 3); color: white;">DAFTAR</a>
</div>
<br>
<div class="col-12" style="display:none;" id="tb_history">
<table class="table-zebra-striping" style="margin-top:5%;">
<tbody>
<tr>
<th>Tgl Daftar</th>
<th>Poli</th>
<th>QR Code</th>
</tr>
</tbody>
<tbody id="history-daftar">
</tbody>
</table>
</div>
</div>
<div id="tb_daftar">
<!-- <div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan">NO. BPJS <b class = "require">*</b></label>
<input type = "number" name = "nobpjs" class="form-control" id = "nobpjs" readonly>
<input type = "hidden" name = "json_peserta" class="form-control" id = "json_peserta" >
</div>
</div>
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan"> <b class = "require"></b></label>
<input type="button" name="cekpeserta" id="cekpeserta" value="Verifikasi BPJS" class="next verifikasi-button cekrm" style = "float:right; width:127px;" />
</div>
</div> -->
<div id="showrujukan" style="display:none; text-align:left">
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<input type="hidden" name="nobpjs" class="form-control" id="nobpjs" readonly="">
<input type="hidden" name="faskes" class="form-control" id="faskes" readonly="">
<input type="hidden" name="tglrujukan" class="form-control" id="tglrujukan" readonly="">
<input type="hidden" name="namafaskes" class="form-control" id="namafaskes" readonly="">
<input type="hidden" name="id_pasien" class="form-control" id="id_pasien" autocomplete="off">
<input type="hidden" name="golpas_id" class="form-control" id="golpas_id" autocomplete="off" readonly="">
<input type="hidden" name="nama" class="form-control" id="nama" autocomplete="off" readonly="" placeholder="Nama dikosongkan.!">
<input type="hidden" name="notelp" class="form-control" id="notelp" readonly="">
<input type="hidden" name="ponsel" class="form-control" id="ponsel" readonly="">
<label class="pay pertanyaan">Surat Rujukan <b class="require">*</b></label>
<input type="hidden" name="json_rujukan" class="form-control" id="json_rujukan">
<input type="hidden" name="norujukan" class="form-control" id="norujukan" readonly="">
<!-- <input type = "hidden" nameaskes" class="form-control" id = "faskes"> -->
<input type="hidden" name="idpolirujukan" class="form-control" id="idpolirujukan">
<input type="hidden" name="kunjunganke" class="form-control" id="kunjunganke" readonly="">
<input type="hidden" name="polisurkon" class="form-control" id="polisurkon" readonly="">
<input type="hidden" name="namapolisurkon" class="form-control" id="namapolisurkon" readonly="">
<input type="hidden" name="tglawalrujukan" class="form-control" id="tglawalrujukan" readonly="">
<label class="pay " id="polirujukan" style="display:none;"><b class="require"></b></label> <input type="button" name="lihatrujukan" id="lihatrujukan" value="Surat Rujukan" class="next selesai-button lihatrujukan" data-toggle="modal"
data-target="#modalShowRujukan1">
</div>
</div>
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12 detailrujukan" id="detailrujukan">
</div>
</div>
</div>
<div id="showsurkon" style="display:none">
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan">NO. SURAT KONTROL <b class="require">*</b></label>
<input type="text" name="surkon" class="form-control" id="surkon">
<input type="hidden" name="idDPJP" class="form-control" id="idDPJP" readonly="">
<input type="hidden" name="tglsurkon" class="form-control" id="tglsurkon" readonly="">
</div>
</div>
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan"> <b class="require"></b></label>
<input type="button" name="ceksurkon" id="ceksurkon" value="Verifikasi Surat Kontrol" class="next verifikasi-button cekrm" style="float:right;width:180px;">
</div>
</div>
</div>
<div id="showtgldaftar" style="display:none; text-align:left">
<div class="row" style="text-align:left">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan">Tanggal Kunjungan <b class="require">*</b></label>
<input type="date" name="tgl_daftar" class="form-control" id="tgl_daftar" min="2024-06-18">
</div>
</div>
<div class="row" style=" margin-top:20px;">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan">Tujuan Poliklinik <b class="require">*</b></label>
<select class="form-control" id="poli" name="poli" style="width:100%">
<option></option>
<option value="ANA" data-nama="ANAK" data-namabpjs="ANAK" id-bpjs="ANA" data-pembatasan="N" data-sesi="1,2,3">ANAK</option>
<option value="BED" data-nama="BEDAH" data-namabpjs="BEDAH" id-bpjs="BED" data-pembatasan="Y" data-sesi="1,2,3">BEDAH</option>
<option value="BDA" data-nama="BEDAH ANAK" data-namabpjs="BEDAH ANAK" id-bpjs="BDA" data-pembatasan="Y" data-sesi="1,2">BEDAH ANAK</option>
<option value="BDIG" data-nama="BEDAH DIGESTIF" data-namabpjs="BEDAH DIGESTIF" id-bpjs="018" data-pembatasan="Y" data-sesi="1,2">BEDAH DIGESTIF</option>
<option value="BORT" data-nama="BEDAH ORTOPEDI" data-namabpjs="ORTHOPEDI" id-bpjs="ORT" data-pembatasan="Y" data-sesi="1,2,3">BEDAH ORTOPEDI</option>
<option value="BDP" data-nama="BEDAH PLASTIK" data-namabpjs="BEDAH PLASTIK" id-bpjs="BDP" data-pembatasan="Y" data-sesi="1,2,3">BEDAH PLASTIK</option>
<option value="BSY" data-nama="BEDAH SARAF" data-namabpjs="BEDAH SARAF" id-bpjs="BSY" data-pembatasan="Y" data-sesi="1,2,3">BEDAH SARAF</option>
<option value="BTRX" data-nama="BEDAH THORAKS" data-namabpjs="BTKV (BEDAH THORAX KARDIOVASKU" id-bpjs="BTK" data-pembatasan="Y" data-sesi="1,2,3">BEDAH THORAKS</option>
<option value="BTMR" data-nama="BEDAH TUMOR" data-namabpjs="BEDAH ONKOLOGI" id-bpjs="017" data-pembatasan="Y" data-sesi="1,2,3">BEDAH TUMOR</option>
<option value="BURO" data-nama="BEDAH UROLOGI" data-namabpjs="UROLOGI" id-bpjs="URO" data-pembatasan="Y" data-sesi="1,2,3">BEDAH UROLOGI</option>
<option value="BVAS" data-nama="BEDAH VASKULER" data-namabpjs="Bedah Vaskuler" id-bpjs="132" data-pembatasan="Y" data-sesi="1,2,3">BEDAH VASKULER</option>
<option value="BDM" data-nama="GIGI BEDAH MULUT" data-namabpjs="GIGI BEDAH MULUT" id-bpjs="BDM" data-pembatasan="N" data-sesi="1,2,3">GIGI BEDAH MULUT</option>
<option value="GND" data-nama="GIGI ENDODONSI" data-namabpjs="GIGI ENDODONSI" id-bpjs="GND" data-pembatasan="N" data-sesi="1,2,3">GIGI ENDODONSI</option>
<option value="PNM" data-nama="GIGI PENYAKIT MULUT" data-namabpjs="GIGI PENYAKIT MULUT" id-bpjs="PNM" data-pembatasan="N" data-sesi="1,2,3">GIGI PENYAKIT MULUT</option>
<option value="GPR" data-nama="GIGI PERIODONSI" data-namabpjs="GIGI PERIODONTI" id-bpjs="GPR" data-pembatasan="N" data-sesi="1,2,3">GIGI PERIODONSI</option>
<option value="PTD" data-nama="GIGI PROSTHODONSI" data-namabpjs="GIGI PROSTHODONTI" id-bpjs="PTD" data-pembatasan="N" data-sesi="1,2,3">GIGI PROSTHODONSI</option>
<option value="JAN" data-nama="JANTUNG" data-namabpjs="JANTUNG DAN PEMBULUH DARAH" id-bpjs="JAN" data-pembatasan="Y" data-sesi="1,2,3">JANTUNG</option>
<option value="JIWA" data-nama="JIWA" data-namabpjs="JIWA" id-bpjs="JIW" data-pembatasan="Y" data-sesi="1,2,3">JIWA</option>
<option value="NUKLIR" data-nama="KEDOKTERAN NUKLIR" data-namabpjs="Kedokteran nuklir" id-bpjs="KDN" data-pembatasan="N" data-sesi="1,2">KEDOKTERAN NUKLIR</option>
<option value="KLT" data-nama="KULIT & KELAMIN" data-namabpjs="KULIT KELAMIN" id-bpjs="KLT" data-pembatasan="N" data-sesi="1,2,3">KULIT & KELAMIN</option>
<option value="MATA" data-nama="MATA" data-namabpjs="MATA" id-bpjs="MAT" data-pembatasan="Y" data-sesi="1,2,3">MATA</option>
<option value="OBG" data-nama="OBSGIN" data-namabpjs="OBGYN" id-bpjs="OBG" data-pembatasan="N" data-sesi="1,2,3">OBSGIN</option>
<option value="OBG_KB" data-nama="OBSGIN ENDOKRINOLOGI REPRODUKSI & KB" data-namabpjs="OBGYN" id-bpjs="OBG" data-pembatasan="N" data-sesi="1,2,3">OBSGIN ENDOKRINOLOGI REPRODUKSI & KB</option>
<option value="OBG_FETO" data-nama="OBSGIN FETOMATERNAL" data-namabpjs="OBGYN" id-bpjs="020" data-pembatasan="N" data-sesi="1,2,3">OBSGIN FETOMATERNAL</option>
<option value="ONKO_GINEKO" data-nama="OBSGIN GINEKOLOGI" data-namabpjs="OBGYN" id-bpjs="021" data-pembatasan="N" data-sesi="1,2,3">OBSGIN GINEKOLOGI</option>
<option value="ONKO" data-nama="OBSGIN ONKOLOGI" data-namabpjs="OBGYN" id-bpjs="021" data-pembatasan="N" data-sesi="1,2,3">OBSGIN ONKOLOGI</option>
<option value="PARU" data-nama="PARU" data-namabpjs="PARU" id-bpjs="PAR" data-pembatasan="Y" data-sesi="1,2,3">PARU</option>
<option value="INT" data-nama="PENYAKIT DALAM" data-namabpjs="PENYAKIT DALAM" id-bpjs="INT" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM</option>
<option value="VCT" data-nama="PENYAKIT DALAM (VCT)" data-namabpjs="PENYAKIT DALAM" id-bpjs="INT" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM (VCT)</option>
<option value="KEMD" data-nama="PENYAKIT DALAM ENDOKRIN METABOLIK DIABETES" data-namabpjs="ENDOKRIN-METABOLIK-DIABETES" id-bpjs="010" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM ENDOKRIN METABOLIK DIABETES</option>
<option value="GASTRO" data-nama="PENYAKIT DALAM GASTRO ENTEROLOGI HEPATOLOGI" data-namabpjs="GASTROENTEROLOGI-HEPATOLOGI" id-bpjs="005" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM GASTRO ENTEROLOGI HEPATOLOGI</option>
<option value="GERIATRI" data-nama="PENYAKIT DALAM GERIATRI" data-namabpjs="Geriatri" id-bpjs="006" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM GERIATRI</option>
<option value="KGH" data-nama="PENYAKIT DALAM GINJAL HIPERTENSI" data-namabpjs="GINJAL-HIPERTENSI" id-bpjs="007" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM GINJAL HIPERTENSI</option>
<option value="GIZI" data-nama="PENYAKIT DALAM GIZI KLINIK" data-namabpjs="GIZI KLINIK" id-bpjs="GIZ" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM GIZI KLINIK</option>
<option value="HEMATO_ONCO" data-nama="PENYAKIT DALAM HEMATOLOGI - ONKOLOGI MEDIK" data-namabpjs="HEMATOLOGI - ONKOLOGI MEDIK" id-bpjs="008" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM HEMATOLOGI - ONKOLOGI MEDIK</option>
<option value="TINFEKSI" data-nama="PENYAKIT DALAM TROPIK INFEKSI" data-namabpjs="PENYAKIT TROPIK-INFEKSI" id-bpjs="014" data-pembatasan="Y" data-sesi="1,2,3">PENYAKIT DALAM TROPIK INFEKSI</option>
<option value="RADTERAPI" data-nama="RADIOTERAPI" data-namabpjs="Radioterapi" id-bpjs="168" data-pembatasan="Y" data-sesi="1,2,3">RADIOTERAPI</option>
<option value="IRM" data-nama="REHABILITASI MEDIK" data-namabpjs="REHABILITASI MEDIK" id-bpjs="IRM" data-pembatasan="Y" data-sesi="1,2">REHABILITASI MEDIK</option>
<option value="SARAF" data-nama="SARAF" data-namabpjs="SARAF" id-bpjs="SAR" data-pembatasan="N" data-sesi="1,2,3">SARAF</option>
<option value="THT" data-nama="THT" data-namabpjs="THT-KL" id-bpjs="THT" data-pembatasan="N" data-sesi="1,2,3">THT</option>
</select>
<span id="poli-error" class="error invalid-feedback"></span>
</div>
</div>
<div class="row" style="text-align:left;">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan">Sesi Kunjungan <b class="require">*</b></label>
<select class="form-control" id="id_andro_sesi" name="id_andro_sesi" style="width:100%">
<option></option> A PHP Error was encountered Severity: Notice Message: Undefined variable: sesi Filename: views/home_new.php Line Number: 344 Backtrace: File: /home/infolahta/public_html/daftaronline/application/views/home_new.php Line:
344 Function: _error_handler File: /home/infolahta/public_html/daftaronline/application/controllers/Home.php Line: 33 Function: view File: /home/infolahta/public_html/daftaronline/index.php Line: 315 Function: require_once A PHP Error was
encountered Severity: Warning Message: Invalid argument supplied for foreach() Filename: views/home_new.php Line Number: 344 Backtrace: File: /home/infolahta/public_html/daftaronline/application/views/home_new.php Line: 344 Function:
_error_handler File: /home/infolahta/public_html/daftaronline/application/controllers/Home.php Line: 33 Function: view File: /home/infolahta/public_html/daftaronline/index.php Line: 315 Function: require_once
</select>
<span id="sesi-error" class="error invalid-feedback"></span>
</div>
</div>
<div class="row" id="showdokter" style="display:none; text-align:left">
<div class="col-12 col-sm-12 col-md-12 col-lg-12">
<label class="pay pertanyaan">Dokter <b class="require">*</b></label>
<input type="hidden" name="dokter" class="form-control" id="dokter">
<input type="hidden" name="namadokter" class="form-control" id="namadokter">
<input type="hidden" name="maxpasien" class="form-control" id="maxpasien">
<!-- <select class="form-control" id="dokter" name="dokter" style = "width:100%">
</select> -->
<input type="button" name="lihatdokter" id="lihatdokter" value="Pilih Dokter" class="next selesai-button lihatdokter" data-toggle="modal" data-target="#modalShowDokter">
</div>
</div>
<div class="row">
<div class="col-12 col-sm-12 col-md-12 col-lg-12 detaildokter">
</div>
</div>
<div class="row" style="display:none" id="tombol-akhir">
<!-- <input type="submit" name="simpan" id="simpan" value="Daftar" class="next verifikasi-button btn btn-md btn-success simpan" style = "float: right;width:80px;"/> -->
<input type="submit" name="simpan" id="simpan" value="Daftar" class="next btn btn-md btn-success simpan" style="float: right;width: 100px;padding: 5px; background:#198754 !important;margin: 10px;">
<input type="button" name="reset" id="reset" value="Muat Ulang" class="next btn btn-md btn-danger reset" style="float: left;width: 100px;padding: 5px;margin: 10px;">
</div>
</div>
</div>
<div class="modal fade" id="modalShowDokter" tabindex="-1" role="dialog" aria-labelledby="modalShowDokterLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="modalShowDokterLabel">Pilih Dokter</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body" id="datadokter">
<div class="modal-footer">
<button type="button" class="btn verifikasi-button" id="modal-btn-si" onclick="document.location.reload(true)" style="width:50px;">Ya</button>
<button type="button" class="btn btn-md btn-danger" data-dismiss="modal" style="width:50px;">Tidak</button>
</div>
</div>
</div>
</div>
</div>
</form>
Text Content
Data Pasien No. Rekam Medis No. BPJS RIWAYAT DAFTAR Tgl Daftar Poli QR Code Surat Rujukan * NO. SURAT KONTROL * Tanggal Kunjungan * Tujuan Poliklinik * ANAKBEDAHBEDAH ANAKBEDAH DIGESTIFBEDAH ORTOPEDIBEDAH PLASTIKBEDAH SARAFBEDAH THORAKSBEDAH TUMORBEDAH UROLOGIBEDAH VASKULERGIGI BEDAH MULUTGIGI ENDODONSIGIGI PENYAKIT MULUTGIGI PERIODONSIGIGI PROSTHODONSIJANTUNGJIWAKEDOKTERAN NUKLIRKULIT & KELAMINMATAOBSGINOBSGIN ENDOKRINOLOGI REPRODUKSI & KBOBSGIN FETOMATERNALOBSGIN GINEKOLOGIOBSGIN ONKOLOGIPARUPENYAKIT DALAMPENYAKIT DALAM (VCT)PENYAKIT DALAM ENDOKRIN METABOLIK DIABETESPENYAKIT DALAM GASTRO ENTEROLOGI HEPATOLOGIPENYAKIT DALAM GERIATRIPENYAKIT DALAM GINJAL HIPERTENSIPENYAKIT DALAM GIZI KLINIKPENYAKIT DALAM HEMATOLOGI - ONKOLOGI MEDIKPENYAKIT DALAM TROPIK INFEKSIRADIOTERAPIREHABILITASI MEDIKSARAFTHT Sesi Kunjungan * A PHP Error was encountered Severity: Notice Message: Undefined variable: sesi Filename: views/home_new.php Line Number: 344 Backtrace: File: /home/infolahta/public_html/daftaronline/application/views/home_new.php Line: 344 Function: _error_handler File: /home/infolahta/public_html/daftaronline/application/controllers/Home.php Line: 33 Function: view File: /home/infolahta/public_html/daftaronline/index.php Line: 315 Function: require_once A PHP Error was encountered Severity: Warning Message: Invalid argument supplied for foreach() Filename: views/home_new.php Line Number: 344 Backtrace: File: /home/infolahta/public_html/daftaronline/application/views/home_new.php Line: 344 Function: _error_handler File: /home/infolahta/public_html/daftaronline/application/controllers/Home.php Line: 33 Function: view File: /home/infolahta/public_html/daftaronline/index.php Line: 315 Function: require_once Dokter * PILIH DOKTER × Ya Tidak QR CODE × . DALAM MASA TRANSISI, MOHON BUKTI PENDAFTARAN INI DICETAK / DIPRINT Tutup PERHATIAN × Anda Yakin? Ya Tidak PERHATIAN × Pendaftaran akan dibatalkan? Ya Tidak PILIH SURAT RUJUKAN × PERHATIAN × Tutup