Registration for Covid-19 Vaccines – Government Vaccine Program. Please fill in the form available below carefully and correctly.

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Please note that:

  • Vaccination is done by certified health practitioners of Abdi Waluyo Hospital Jakarta
  • Vaccination is for Indonesian Citizens 18 years old and above, Foreigners 60 years old and above, or Foreign teachers
  • Indonesian vaccine receivers must have KTP (National ID Card) DKI Jakarta, or Certificate of Domicile from RT/RW in DKI Jakarta
  • Foreign vaccine receivers must have KITAS/KITAP with 16-digit NIK
  • Registration for COVID-19 vaccination for Indonesian citizens 18 years old and above must be done through RS Abdi Waluyo mobile app.

Vaccine Recipient Biodata

I once went to Abdi Waluyo Hospital for treatment

Identity Card
Personal Data

Date of birth – press year for easier selection

I never went to Abdi Waluyo Hospital for treatment

Identity Card
Personal Data

Date of birth – press year for easier selection

Contact Information

Residence address (domicile) – please fill this if your current address is different from your ID card’s address

Relative Data
Emergency Contact

COVID-19 Vaccination Approval

COVID-19 Vaccine administration in Abdi Waluyo Hospital is a 2-dose-vaccination and must be started from dose 1.
 

Informed Consent

I, who filled this information, hereby stated that I understand and agree to:
  1. Undergo a 2-dose COVID-19 vaccination
    1. The second dose will be administered 12 weeks after the first dose.
    2. The second dose of COVID-19 vaccination will be administered at the same health care facilities as the first dose.
  2. The risk of side effects after COVID-19 vaccination including pain and/or redness near the vaccinated area, malaise, headache, muscle pain, fever, allergic reaction, and other symptoms that may occur depend on people’s body condition.
  3. After receiving vaccination, I will undergo a 15-minute observation at the health care facility.
  4. Those who have received COVID-19 vaccination may still get a COVID-19 infection and pass it to others. Vaccination does not guarantee a complete immunity from COVID-19, it simply improves the immunity against COVID-19 infection so that if we did get infected, the disease severity would be less compared to those who have not been vaccinated.
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