diff --git a/app/components/app/cemotherapy/entry-form.vue b/app/components/app/cemotherapy/entry-form.vue
new file mode 100644
index 00000000..1b6e9140
--- /dev/null
+++ b/app/components/app/cemotherapy/entry-form.vue
@@ -0,0 +1,306 @@
+<script setup lang="ts">
+// Components
+import Block from '~/components/pub/my-ui/doc-entry/block.vue'
+import Cell from '~/components/pub/my-ui/doc-entry/cell.vue'
+import Field from '~/components/pub/my-ui/doc-entry/field.vue'
+import Label from '~/components/pub/my-ui/doc-entry/label.vue'
+import Button from '~/components/pub/ui/button/Button.vue'
+import Combobox from '~/components/pub/my-ui/combobox/combobox.vue'
+import Input from '~/components/pub/ui/input/Input.vue'
+import DatepickerSingle from '~/components/pub/my-ui/datepicker/datepicker-single.vue'
+
+// Types
+import type { Ref } from 'vue'
+import type { PaginationMeta } from '~/components/pub/my-ui/pagination/pagination.type'
+
+// Helpers
+import type z from 'zod'
+import { useForm } from 'vee-validate'
+import { toTypedSchema } from '@vee-validate/zod'
+
+interface Props {
+  schema: z.ZodSchema<any>
+  values?: any
+  isLoading?: boolean
+  isReadonly?: boolean
+}
+
+const props = defineProps<Props>()
+const isLoading = props.isLoading !== undefined ? props.isLoading : false
+const isReadonly = props.isReadonly !== undefined ? props.isReadonly : false
+
+const items = [
+  { value: 'item-1', label: 'Item 1' },
+  { value: 'item-2', label: 'Item 2' },
+  { value: 'item-3', label: 'Item 3' },
+]
+
+const emit = defineEmits<{
+  submit: [values: any, resetForm: () => void]
+  cancel: [resetForm: () => void]
+}>()
+
+const { defineField, errors, meta } = useForm({
+  validationSchema: toTypedSchema(props.schema),
+  initialValues: {
+    namaPasien: '',
+    tanggalLahir: '',
+    noRM: '',
+    alamat: '',
+    beratBadan: '',
+    tinggiBadan: '',
+    diagnosa: '',
+    siklus: '',
+    periodeAwal: '',
+    periodeAkhir: '',
+    tanggalKemoterapi: '',
+    dokterKRJ: '',
+  },
+})
+
+// Define form fields
+const [namaPasien, namaPasienAttrs] = defineField('namaPasien')
+const [tanggalLahir, tanggalLahirAttrs] = defineField('tanggalLahir')
+const [noRM, noRMAttrs] = defineField('noRM')
+const [alamat, alamatAttrs] = defineField('alamat')
+const [beratBadan, beratBadanAttrs] = defineField('beratBadan')
+const [tinggiBadan, tinggiBadanAttrs] = defineField('tinggiBadan')
+const [diagnosa, diagnosaAttrs] = defineField('diagnosa')
+const [siklus, siklusAttrs] = defineField('siklus')
+const [periodeAwal, periodeAwalAttrs] = defineField('periodeAwal')
+const [periodeAkhir, periodeAkhirAttrs] = defineField('periodeAkhir')
+const [tanggalKemoterapi, tanggalKemoterapiAttrs] = defineField('tanggalKemoterapi')
+const [dokterKRJ, dokterKRJAttrs] = defineField('dokterKRJ')
+
+// Set initial values if provided
+if (props.values) {
+  Object.entries(props.values).forEach(([key, value]) => {
+    if (value !== undefined) {
+      const field = defineField(key)[0]
+      field.value = value
+    }
+  })
+}
+
+const resetForm = () => {
+  // Object.keys(meta.value.initialValues).forEach((key) => {
+  //   const field = defineField(key)[0]
+  //   field.value = ''
+  // })
+}
+
+function onSubmitForm() {
+  const formData = {
+    namaPasien: namaPasien.value,
+    tanggalLahir: tanggalLahir.value,
+    noRM: noRM.value,
+    alamat: alamat.value,
+    beratBadan: beratBadan.value,
+    tinggiBadan: tinggiBadan.value,
+    diagnosa: diagnosa.value,
+    siklus: siklus.value,
+    periodeAwal: periodeAwal.value,
+    periodeAkhir: periodeAkhir.value,
+    tanggalKemoterapi: tanggalKemoterapi.value,
+    dokterKRJ: dokterKRJ.value,
+  }
+  emit('submit', formData, resetForm)
+}
+
+function onCancelForm() {
+  emit('cancel', resetForm)
+}
+</script>
+
+<template>
+  <form @submit.prevent>
+    <!-- Data Pasien Section -->
+    <div class="mb-6">
+      <h3 class="mb-4 text-lg font-semibold">Data Pasien</h3>
+      <Block
+        labelSize="thin"
+        class="!mb-2.5 !pt-0 xl:!mb-3"
+      >
+        <Cell>
+          <Label height="compact">Nama Pasien</Label>
+          <Field :errMessage="errors.namaPasien">
+            <Input
+              v-model="namaPasien"
+              v-bind="namaPasienAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Masukkan nama pasien"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">Tanggal Lahir</Label>
+          <Field :errMessage="errors.tanggalLahir">
+            <DatePicker
+              v-model="tanggalLahir"
+              v-bind="tanggalLahirAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Pilih tanggal lahir"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">No. RM</Label>
+          <Field :errMessage="errors.noRM">
+            <Input
+              v-model="noRM"
+              v-bind="noRMAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Masukkan nomor RM"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">Alamat</Label>
+          <Field :errMessage="errors.alamat">
+            <Input
+              v-model="alamat"
+              v-bind="alamatAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Masukkan alamat"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">Berat Badan</Label>
+          <Field :errMessage="errors.beratBadan">
+            <Input
+              v-model="beratBadan"
+              v-bind="beratBadanAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Masukkan berat badan"
+              type="number"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">Tinggi Badan</Label>
+          <Field :errMessage="errors.tinggiBadan">
+            <Input
+              v-model="tinggiBadan"
+              v-bind="tinggiBadanAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Masukkan tinggi badan"
+              type="number"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">Diagnosa</Label>
+          <Field :errMessage="errors.diagnosa">
+            <Combobox
+              id="diagnose"
+              v-model="diagnosa"
+              v-bind="diagnosaAttrs"
+              :items="items"
+              :is-disabled="isLoading || isReadonly"
+              placeholder="Tentukan diagnosa pasien"
+              search-placeholder="Cari diagnosa"
+              empty-message="Diagnosa tidak ditemukan"
+            />
+          </Field>
+        </Cell>
+      </Block>
+    </div>
+
+    <!-- Protokol Kemoterapi Section -->
+    <div class="mb-6">
+      <h3 class="mb-4 text-lg font-semibold">Protokol Kemoterapi</h3>
+      <Block
+        labelSize="thin"
+        class="!mb-2.5 !pt-0 xl:!mb-3"
+      >
+        <Cell>
+          <Label height="compact">Siklus</Label>
+          <Field :errMessage="errors.siklus">
+            <Input
+              v-model="siklus"
+              v-bind="siklusAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Masukkan siklus"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">Periode</Label>
+          <div class="flex items-center gap-4">
+            <Field
+              :errMessage="errors.periodeAwal"
+              class="flex-1"
+            >
+              <DatepickerSingle
+                v-model="periodeAwal"
+                v-bind="periodeAwalAttrs"
+                :disabled="isLoading || isReadonly"
+                placeholder="Mulai Periode"
+              />
+            </Field>
+            <span>Sampai</span>
+            <Field
+              :errMessage="errors.periodeAkhir"
+              class="flex-1"
+            >
+              <DatepickerSingle
+                v-model="periodeAkhir"
+                v-bind="periodeAkhirAttrs"
+                :disabled="isLoading || isReadonly"
+                placeholder="Akhir Periode"
+              />
+            </Field>
+          </div>
+        </Cell>
+        <Cell>
+          <Label height="compact">Tanggal Kemoterapi</Label>
+          <Field :errMessage="errors.tanggalKemoterapi">
+            <DatepickerSingle
+              v-model="tanggalKemoterapi"
+              v-bind="tanggalKemoterapiAttrs"
+              :disabled="isLoading || isReadonly"
+              placeholder="Pilih tanggal kemoterapi"
+            />
+          </Field>
+        </Cell>
+        <Cell>
+          <Label height="compact">Dokter Ruang Tindakan</Label>
+          <Field :errMessage="errors.dokterKRJ">
+            <Combobox
+              id="doktor"
+              v-model="dokterKRJ"
+              v-bind="dokterKRJAttrs"
+              :items="items"
+              :is-disabled="isLoading || isReadonly"
+              placeholder="Pilih dokter"
+              search-placeholder="Cari dokter"
+              empty-message="Dokter tidak ditemukan"
+            />
+          </Field>
+        </Cell>
+      </Block>
+    </div>
+
+    <!-- Form Actions -->
+    <div class="flex justify-end gap-2 py-2">
+      <Button
+        type="button"
+        variant="secondary"
+        class="w-[120px]"
+        @click="onCancelForm"
+      >
+        Kembali
+      </Button>
+      <Button
+        v-if="!isReadonly"
+        type="button"
+        class="w-[120px]"
+        :disabled="isLoading || !meta.valid"
+        @click="onSubmitForm"
+      >
+        Simpan
+      </Button>
+    </div>
+  </form>
+</template>