General Public Registration
Data Privacy: By filling up this form, you consent to the inclusion of your response and personal data in the Vaccination Program which will used by LGU Mangaldan in its planning and policy formulation. Rest assured, all information are treated with utmost confidentiality.
*Please accomplish the form ONCE ONLY. Double Check before submission. (Put N/A for Not Applicable)
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Priority Group *
Category_ID *
Category_ID_Number *
PhilHealth_ID *
PWD ID *
Last_Name *
First_Name *
Middle_Name *
Suffix *
Contact_No. (If NONE, indicate any contact number/s for us to easily contact you. Please never indicate N/A or Not Applicable on contact nos. ) *
Current_Residence:_Unit/Building/House_Number,_Street_Name *
Current_Residence:_Region *
Current_Residence:Province *
Current_Residence:Municipality/City *
Current_Residence:Barangay *
Sex *
Birthdate_mm/dd/yyyy_ *
MM
/
DD
/
YYYY
Civil_Status *
Employment_Status *
Profession/Occupation *
Name_of_Employer *
Province/HUC/ICC_of_Employer *
Address_of_Employer *
Contact_number_of_Employer *
Pregnancy_status
Clear selection
Drug_Allergy? *
Food_Allergy? *
Insect_Allergy? *
Latex_Allergy? *
Mold_Allergy? *
Pet_Allergy? *
Pollen_Allergy? *
With_Comorbidity? *
Hypertension *
Heart_Disease *
Kidney_Disease *
Diabetes_Mellitus *
Bronchial_Asthma *
Immunodeficiency_Status *
Cancer *
Others
Patient_was_diagnosed_with_COVID_19 *
Date_of_first_positive_result_/_specimen_collection_mm/dd/yyyy_
MM
/
DD
/
YYYY
Classification_of_COVID_19
Clear selection
Provided_Electronic_Informed_Consent? *
Submit
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