Baliwag Covid-19 Vaccination Registration Form

(12-17 years old)

Scan your iAmSafe QR Code to autofill your personal details

*Check if all the information provided below are correct*

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Firstname

Middlename

Lastname

Mobile Number

Sector

Other Category

Sex

Birthday

Province

City/Municipality

Barangay

House Number

Prefered Vaccine Note: Selecting prefered vaccine doesn't guarantee the vaccine that will be given to you.

IamSafe QR Code

Philhealth ID

Allergies

Drug Allergy

Food Allergy

Insect Allergy

Latex Allergy

Mold Allergy

Pet Allergy

Pollen Allergy

Other Allergies

Existing Medical Condition

Hypertension

Heart Disease

Kidney Disease

Diabetes Melitus

Bronchial Asthma

Immunodeficiency

Cancer

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

Guardian's Fullname

Firstname

Middlename

Lastname

Upload following documents for your application validation.

Patient ID
Guardian ID
Hospital Document is optional but you must bring this on the day of vaccination.

Drop/Click here to upload other supporting documents.