CoViD-19 Vaccination Pre-Registration Form (Malay, Aklan)
Please fill-up the following questions.
Last Name *
First Name *
Middle Name *
Suffix (ex. Jr. Sr.) *
Sex *
Birthdate *
MM
/
DD
/
YYYY
Contact No. *
Email
Address (Barangay) *
Address (Zone/Sitio) *
Occupation *
Allergy to vaccines or components of vaccines? *
With Comorbidity? *
With Comorbidity? (please specify if others)
Priority Group *
Worker or Resident? *
Submit
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