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<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<title>Untitled Document</title>
<style type="text/css">
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.style1 {font-family: Arial, Helvetica, sans-serif}
.style26 {font-family: Arial, Helvetica, sans-serif; font-size: small; }
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</style>
	<style>
table {
    border-collapse: collapse;
    border: 1px solid black;
}
</style>
</head>

<body onload="document.formVerif.NoRM.focus()">
<label></label><table width="505" border="0" align="center" bordercolor="#000000">
  <tr>
    <td><div align="center"><img src="kopnu.png" alt="RSINU DEMAK" width="496" height="87"/></div></td>
  </tr>
</table>
	<br>
	<form name=formVerif method=post action="cekVerif.php">
		
<table width="888" height="118" border="0" align="center" bordercolor="#000000">
  <tr>
    <th width="269" ><div align="left" class="style1">Nomor Rekam Medik </div></th>
    <td width="10"><span class="style1">:</span></td>
    <td width="601">
      <input name="NoRM" type="text" id="NoRM" required/>
    </td>
  </tr>
  <tr>
    <th scope="row"><div align="left" class="style1">Tanggal Lahir (Hari/Bulan/Tahun) </div></th>
    <td><span class="style1">:</span></td>
    <td>
      <input name="Tgl" type="date" id="myLocalDate" step=".1" required/>
    </td>
  </tr>
  <tr>
    <th height="28" scope="row"></th>
    <td>&nbsp;</td>
    <td>
      <input name="submit" type="submit" value="Verifikasi" />
    </td>
  </tr>
</table>


			
	</form>

<p>&nbsp;</p>
<p>&nbsp;</p>
</body>
</html>
