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LGU of San Mateo, Rizal: Vaccine Registration Form
Answer the following questions and make sure that the information you give is accurate and complete.
(Ang vaccine registration form na ito ay para lamang sa residente ng San Mateo, Rizal)
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* Indicates required question
Email
*
Your email
LOCAL GOVERNMENT OF SAN MATEO RIZAL COVID VACCINE PROGRAM
Date of Filing
*
MM
/
DD
/
YYYY
Category
*
01_Health_Care_Worker
02_Senior_Citizen
03_Indigent
04_Uniformed_Personnel
05_Essential_Worker
06_Other
07_Comorbidities
08_Teachers_Social_Workers
09_Other_Govt_Workers
10_Other_High_Risk
11_OFW
12_Remaining_Workforce
13_Pediatric
Category ID
*
01_PRC_number
02_OSCA_number
03_Facility_ID_number
04_Other_ID
ID number (Write N/A if not applicable)
*
Your answer
Philhealth Number (Write N/A if not applicable)
*
Your answer
PWD ID Number (Write N/A if not applicable)
*
Your answer
SURNAME
*
Your answer
FIRST NAME
*
Your answer
MIDDLE NAME
Your answer
Suffix (ex: JR., SR., IIII)
Your answer
Contact Number
*
Your answer
Address (House number, Street name, Subdivision/NOA)
*
Your answer
Current Residence Region
*
CALABARZON
Required
Province
*
_0458_RIZAL
Municipality
*
_45811_SAN_MATEO
Barangay
*
Choose
_45811001_AMPID_I
_45811002_DULONG_BAYAN_1
_45811003_DULONG_BAYAN_2
_45811004_GUINAYANG
_45811005_GUITNANG_BAYAN_I_(POB.)
_45811006_GUITNANG_BAYAN_II_(POB.)
_45811007_MALANDAY
_45811008_MALY
_45811010_SANTA_ANA
_45811011_AMPID_II
_45811012_BANABA
_45811013_GULOD_MALAYA
_45811014_PINTONG_BOCAWE
_45811015_SANTO_NIÑO
_45811016_SILANGAN
Gender
*
01_Female
02_Male
Date of Birth
*
MM
/
DD
/
YYYY
Civil Status
*
01_Single
02_Married
03_Widow/Widower
04_Separated/Annulled
05_Living with Partner
Employment Status
*
01_Government_Employed
02_Private_Employed
03_Self_Employed
04_Private_Practitioner
05_Others
Directly interact with COVID patient?
*
01_Yes
02_No
Profession
*
Choose
01_Dental_Hygienist
02_Dental_Technologist
03_Dentist
04_Medical_Technologist
05_Midwife
06_Nurse
07_Nutritionist_Dietician
08_Occupational_Therapist
09_Optometrist
10_Pharmacist
11_Physical_Therapist
12_Physician
13_Radiologic_Technologist
14_Respiratory_Therapist
15_X_ray_Technologist
16_Barangay_Health_Worker
17_Maintenance_Staff
18_Administrative_Staff
19_Others_
20_Student
Name of Employer/School for students (Write NA if not applicable)
*
Your answer
Municipality of Employer
*
Your answer
Address of employer (Write NA if not applicable)
*
Your answer
Contact number of employer (Write NA if not applicable)
*
Your answer
Pregnancy Status
*
01_Pregnant
02_Not_Pregnant
Drug Allergy
*
01_Yes
02_No
Food Allergy
*
01_Yes
02_No
Insect Allergy
*
01_Yes
02_No
Latex Allergy ( Example of latex are gloves, condoms, balloons etc.)
*
01_Yes
02_No
Mold Allergy
*
01_Yes
02_No
Pet Allergy
*
01_Yes
02_No
Pollen Allergy
*
01_Yes
02_No
With co-morbidities (hypertension, chronic illness, heart illness etc.)
*
01_Yes
02_No
Hypertension
*
01_Yes
02_No
Heart Disease
*
01_Yes
02_No
Kidney Disease
*
01_Yes
02_No
Diabetes
*
01_Yes
02_No
Bronchial Asthma
*
01_Yes
02_No
Immunodeficiency
*
01_Yes
02_No
Cancer
*
01_Yes
02_No
Other Disease (Write NA if not applicable)
*
Your answer
Diagnosed with COVID-19
*
01_Yes
02_No
If yes, date of most recent positive result
MM
/
DD
/
YYYY
If yes, classification of COVID-19
01_Asymptomatic
02_Mild
03_Moderate
04_Severe
05_Critical
NA
Clear selection
I hereby understand that upon submitting this form, I signify my willingness to undertake the COVID-19 vaccine.
*
01_Yes
Required
A copy of your responses will be emailed to the address you provided.
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