Electronic Patient Registration Form
This form will be filled up by the patients once per laboratory in order for them to receive their unique QR Code and Retrieval Code via the email they will be providing. Once the form has been accomplished, the patient can now book their test.
Take note of the fields with highlights, these are the fields that are required to be filled out and the rest are optional.
Here are the steps that the patients need to follow for their patient registration:
Visit the link provided by the laboratory where you will be booking an appointment with.
Provide the required information highlighted in the form.
Save a copy of the retrieval code and QR code that would show up once you finish answering the form. The same information will be sent to the email the patient provided on the registration form.
Bring a copy of your retrieval code and QR code and present these to the laboratory personnel on the day of your appointment.
Here's the list of the information that the patients need to provide for the Patient Electronic Registration Form (e-CIF):
Required Fields | Optional Fields |
Patient Information | Patient Vaccination Record |
Patient Employment Information | Profile Photo |
Identity Document | Philhealth ID |
Current Address | PWD ID |
Permanent Address | Travel Details |
Phone Number | Patient SARS-COV2 Exposure History |
Patient Medical Record | |
Patient Clinical Record | |
Quarantine Facility |
Walkthrough of Electronic Patient Registration Form
Patient Information
Provide basic information for documentation:
Last name
First name
Middle name
Birthday
Sex
Civil Status
Email
Confirm email
Emergency contact name (optional)
Emergency contact number (optional)
Click the box if you’re a member of an indigenous group and select what group you are a part of.
Patient Vaccination Record
Provide information of your vaccination status (if any)
If the user is vaccinated, provide the following details:
Vaccination category
Vaccine brand
Date of vaccine dose
Vaccination facility
Region of vaccination facility
Adverse reaction to this vaccine dose (optional)
Patient Employment Information
Provide information about your employment status:
Occupation
Department in work (optional)
Employer name (optional)
Employment Address (optional)
Work industry (optional)
I am a returning OFW
Click the box if you’re an OFW (Overseas Filipino Worker). If not, leave it blank.
Patient Profile Photo
This is an optional field for some laboratories but there are laboratories that would need this for verification.
Identity Document (ID)
User may choose from any of the following documents for the verification of their identity:
Barangay ID
Driver's license
OFW (Overseas Filipino Worker) ID
Others
PAG-IBIG ID
Passport
PhilHeatlh ID
Postal ID
PRC (Philippine Regulatory Commissions) ID
PWD (Person with Disability) ID
Senior citizen ID
SSS (Social Security System) UMID
Student
TIN (Tax Identification Number)
Voter's ID
Work
Make sure that the ID you will be using comes with a valid ID number.
PhilHealth ID (optional)
Some laboratories will need this in case the laboratory or test fees are subsidized by PhilHealth.
Person with Disability (PWD) ID (optional)
Click the checkbox if you are a person with a disability and input your ID details:
PWD ID photo
PWD ID number
This is an optional field. Fill this up in case the laboratory might need to prepare to give proper assistance during the laboratory visit.
Current Address
Provide the following information:
Province
City
Barangay
House number or building/subdivision
Street name
Postal code (optional)
Notable nearby landmarks
The region will automatically update itself once you have chosen your province.
Permanent Address
If the patient's Current Address and Permanent Address are the same, kindly click the box next to “Same as previous address.”
If the patient's permanent address is different from their current address, provide the following:
Province
City
Barangay
House number or building/subdivision
Street name
Postal code (optional)
Notable nearby landmarks
Phone Number
Provide a phone number in case the laboratory would need to get in touch with you.
Travel Details (optional)
Click the check box if you will be traveling via plane.
If you are traveling, please provide the following details:
Origin
Destination
Flight vessel number
Travel company / Airline
Date and time of travel
Patient SARS-COV 2 Exposure History (optional)
Choose from the drop-down box if you were exposed to a potential SARS-COV2 case:
SARS-COV 2
SARS-COV 2 possible transmission
Patient Medical Record (optional)
Click the box next to the option that applies to the patient.
Patient Clinical Record (optional)
Click the box next to the option that applies to the patient.
Quarantine Facility (optional)
Choose an option from the drop-down box if the patient went under quarantine.
Declaration of Data Privacy and Consent
This is to ensure the patients that the information provided will only be used by the lab.
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