Formulir Rekomendasi Izin PraktikPERMOHONANBARUPERPANJANGANJENIS LAYANANPRAKTIK MANDIRIKLINIK HEWANRUMAH SAKIT HEWANANGGOTA PDHI CABANGANGGOTA PDHI CABANGJAWA BARAT 5ACEHBALIBANGKA BELITUNGBANTEN 1BANTEN 2BENGKULUDIYDKI JAKARTAGORONTALOJAMBIJAWA BARAT 1JAWA BARAT 2JAWA BARAT 3JAWA BARAT 4JAWA BARAT 6JAWA BARAT 7JAWA BARAT 8JAWA TENGAH 1JAWA TENGAH 2JAWA TENGAH 3JAWA TENGAH 4JAWA TENGAH 5JAWA TENGAH 6JAWA TIMUR 1JAWA TIMUR 2JAWA TIMUR 3JAWA TIMUR 4JAWA TIMUR 5JAWA TIMUR 6JAWA TIMUR 7JAWA TIMUR 8JAWA TIMUR 9JAWA TIMUR 10KALIMANTAN BARATKALIMANTAN SELATANKALIMANTAN TENGAHKALIMANTAN TIMUR 1KALIMANTAN TIMUR 2KALIMANTAN UTARA 1KEPULAU RIAULAMPUNGMALUKU UTARANTB 1NTB 2NTTPAPUAPAPUA BARATPAPUA SELATANRIAUSULAWESI SELATAN & SULAWESI BARATSULAWESI TENGAHSULAWESI TENGGARASULAWESI UTARASUMATRA BARATSUMATRA SELATANSUMATRA UTARASurat Keterangan Pengurusan Rekomendasi dari Cabang Asal *Choose FileNo file chosenDelete uploaded fileDATA PRIBADINAMA *JENIS KELAMIN *JENIS KELAMINLAKI-LAKIPEREMPUANTEMPAT LAHIR *TANGGAL LAHIR *Phone *Email Address *Alamat Domisili *CityProvinsiKode PosCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweDATA PROFESI DOKTER HEWANMulai Praktik Tahun *No. Anggota *NAMA TEMPAT PRAKTIK (MANDIRI/ KLINIK/RSH) *ALAMAT PRAKTIK (MANDIRI/KLINIK/RSH) *JAM PRAKTEKEMAIL (MANDIRI/ KLINIK/RSH)TELEPON (MANDIRI/ KLINIK/RSH) *Dokter Hewan Lain (bila ada dan harap diisi, baik yang sudah ada izin atau belum)NAMA LENGKAPNo.SIPFASILITAS TEMPAT PRAKTIK (MANDIRI/KLINIK/RSH)LAYANAN *PilihMANDIRIKLINIKRSHA. Ruang Praktik *RUANG PERIKSARUANG TUNGGURUANG REPARASIRUANG OPERASIRUANG RAWAT INAP NON-INFEKSIUS (Minimal 10 Ekor Hewan)RUANG RAWAT INAP INFEKSIUS (Minimal 10 Ekor Hewan)B. ALAT MEDISTHERMOMETERENDOSCOPISTETOSCOPEMICROSCOPEUSGX-RAYALAT OPERASI MAYORALAT OPERASI MINOROTOSCOPE-OPTHALMOSCOPEMESIN ANAESTHESI GASELECTRO CARDIOGRAFILAINNYAC. ALAT PENUNJANG PRAKTIK *MEJA PRAKTIKLEMARI OBATTIMBANGANMEJA OPERASIREKAM MEDISSTERILISATORCOLER BOX / CHILLER / KULKASD. LABORATORIUMPARASITOLOGIHEMATOLOGIKIMIA DARAHCITOLOGIPATOLOGIURINALISISPCR (Polymerase Chain Reaction)IMMUNOFLUORESCENT ANALYZERE. INVENTARIS OBAT *ANTIBIOTIKAANTIPRIRETIKAANALGESICANTIHISTAMINADRENALINCORTICOSTEROIDSEDATIVAANESTESIAINFUSANTISEPTIKAVAKSINOBAT ORALF. MANAJEMEN (Khusus Klinik/ RSH) *PENGALAMAN PENANGGUNG JAWAB SEBAGAI DOKTER HEWAN PRAKTEK> 2TAHUNUpload Bukti Surat Pengalaman KerjaDrag and Drop (or) Choose FilesKELENGKAPAN BERKASPAS FOTO (1 LEMBAR) *Choose FileNo file chosenDelete uploaded fileKTP 1 (LEMBAR) *Choose FileNo file chosenDelete uploaded fileIjazah Dokter Hewan (Drh.) (1 Lembar) *Choose FileNo file chosenDelete uploaded fileKartu Tanda Anggota PDHI Cabang Asal (1 Lembar) * *Choose FileNo file chosenDelete uploaded fileSurat Tanda Registrasi Veteriner (STRV) (1 Lembar) * *Choose FileNo file chosenDelete uploaded fileIjazah Dokter Hewan (S.K.H) (1 Lembar) * *Choose FileNo file chosenDelete uploaded fileSurat Keterangan Orientasi Klinik (1 Lembar) * *Choose FileNo file chosenDelete uploaded fileUpload Video Lokasi dan Fasilitas (Praktik/ Klinik/ RSH)Upload videoDrag and Drop (or) Choose FilesBukti Pembayaran ( Survey Lokasi/ Rekomendasi Izin/ Iuran) *Upload GambarDrag and Drop (or) Choose FilesUNDUH SURAT PERNYATAAN 📥 UNDUH UPLOAD SURAT PERNYATAAN *Choose FileNo file chosenDelete uploaded fileSubmit
