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  • Please fill all the required fields it is indicated with a "*" symbol at the end of the field name
  • Make sure that Image size of your ID is 2000 kb or 2mb below. you can use to reduce the size of image
  • Please use your GMAIL for the email field
  • The format for Date of Birth is (day/month/year)/(dd/mm/yyyy)
  • Please Select Others On Employment Status if you are a Student or currently Unemployed

Priority Group *

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Category ID *

Category ID Number

Type the Id number based on the category that you have been selected
Please upload an image of your ID with the ID number that you have type in ID number field


Patient Information

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Health Information



City Health Office is committed to maintaining the privacy of personal data obtained in the use of this program. Coincident to this compliance is our acknowledgement that the personal information we collect and process are handled in observance of the minimum standards defined under Republic Act No. 10173 (“Data Privacy Act of 2012” or “DPA”) and its own internal Privacy Rules.

As a patient who provides personal information and sensitive personal information to City Health Office, you hereby authorize and consent to the collection, use, processing, and transfer of said information according to well-founded and legitimate purposes. Further, you hereby authorize the sharing of said information to regulatory bodies or local government units to allow City Health Office to meet its commitments under applicable laws, regulations, including contractual commitments. We may further collect or disclose necessary information from our subsidiaries and affiliates or other agencies as allowed by the law.

City Health Office is also committed to perpetuate the integrity, availability and confidentiality of your information against any occurrences or breaches while ensuring the protection of the fundamental right of privacy. This commitment applies to all involved in this program. Processing of information will only be done when patient has already given his/her consent prior to the collection of his/her data or as soon as practicable and reasonable.

Any form of transferring, sharing, or outsourced processing of your personal information shall be carried out in observance with guidelines set under the law through an agreement

By checking the box you agree that the all data that you have provide is true