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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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Email *
LOCAL GOVERNMENT OF SAN MATEO RIZAL COVID VACCINE PROGRAM
Date of Filing *
MM
/
DD
/
YYYY
Category *
Category ID *
ID number   (Write N/A if not applicable) *
Philhealth Number   (Write N/A if not applicable) *
PWD ID Number     (Write N/A if not applicable) *
SURNAME *
FIRST NAME *
MIDDLE NAME
Suffix (ex: JR., SR., IIII)
Contact Number *
Address (House number, Street name, Subdivision/NOA) *
Current Residence Region *
Required
Province *
Municipality *
Barangay *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Civil Status *
Employment Status *
Directly interact with COVID patient? *
Profession *
Name of Employer/School for students (Write NA if not applicable) *
Municipality of Employer *
Address of employer        (Write NA if not applicable) *
Contact number of employer     (Write NA if not applicable) *
Pregnancy Status *
Drug Allergy *
Food Allergy *
Insect Allergy *
Latex Allergy ( Example of latex are gloves, condoms, balloons etc.) *
Mold Allergy *
Pet Allergy *
Pollen Allergy *
With co-morbidities (hypertension, chronic illness, heart illness etc.) *
Hypertension *
Heart Disease *
Kidney Disease *
Diabetes *
Bronchial Asthma *
Immunodeficiency *
Cancer *
Other Disease    (Write NA if not applicable) *
Diagnosed with COVID-19 *
If yes, date of most recent positive result
MM
/
DD
/
YYYY
If yes, classification of COVID-19
Clear selection
I hereby understand that upon submitting this form, I signify my willingness to undertake the COVID-19 vaccine. *
Required
A copy of your responses will be emailed to the address you provided.
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