Baliwag Covid-19 Vaccination Registration Form

Scan your iAmSafe QR Code to autofill your personal details

*Check if all the information provided below are correct*

If camera doesnt work, click this link and follow the steps.

Firstname
Middlename
Lastname
Mobile Number
Sector
Other Category
Sex
Birthday
Province
City/Municipality
Barangay
House Number
Employed?
Business Owner?
IamSafe QR Code
Philhealth ID

Allergies

Other Allergies

Existing Medical Condition

Other Disease
Are you willing to be vaccinated?
Reason
Exposed to a confirmed covid case?
Date Exposed
Diagnosed with Covid-19?
Date Positive
Previously diagnosed but recovered?
Date Recovered
Drop files here to upload