Dumaguete City Health Office - COVID-19 Vaccination (Pre-Registration Form)
Congratulations on taking this STEP to protecting yourself and your family from COVID-19. Please ensure information provided below is correct and complete! Salamat!
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Category *
Choose ONLY 1 that best classifies you:
Required
Willing to be vaccinated? *
Patient with Disability (PWD)? Y for Yes, N for No *
Indigenous Member *
Last Name *
First Name *
Middle Name *
Suffix *
Contact Number *
Region *
Province *
City *
Barangay *
Sex *
Birthdate *
MM
/
DD
/
YYYY
Pregnant *
Email Address *
Name of Accompanying Parent/Guardian for Minors (LAST Name, FIRST Name) *
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