Form Pendaftaran UPT. Puskeswan

Nama Depan
Field is required!
Nama Belakang:
Field is required!
NIK KTP
Field is required!
Kecamatan
  • – Pilih –
  • Kapuas
  • Mukok
  • Parindu
  • Meliau
  • Bonti
  • Tayan Hulu
  • Balai
  • Tayan Hilir
  • Kembayan
  • Beduai
  • Sekayam
  • Entikong
  • Noyan
  • Jangkang
Field is required!
Kelurahan/Desa
Field is required!
Puskeswan
  • – Pilih –
  • Kapuas
  • Mukok
  • Tayan Hulu
  • Balai Batang Tarang
  • Tayan Hilir
  • Kembayan
  • Sekayam
Field is required!
No. Tlp/Wa
Field is required!
Jenis hewan
  • – Pilih –
  • Sapi
  • Babi
  • Anjing
  • Kucing
  • Kera
  • Munsang
  • Lainnya
Field is required!
Jenis Kelamin
  • – Pilih –
  • Jantan
  • Betina
Field is required!
Umur hewan (bulan)
+
Field is required!
Jumlah hewan
+
Field is required!
Jenis layanan
  • – Pilih –
  • Pengobatan
  • Vaksinasi
  • Lainnya
Field is required!
Tanggal daftar
Field is required!
Tanggal Kedatangan
Field is required!
Waktu Kedatangan
Field is required!

Waktu pelayanan publik buka setiap hari kerja (Senin-Jumat) Pukul 07.30-15.30 WIB)