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. You can request for your RM's to change the require and shown fields.

Walkthrough of Electronic Patient Registration Form

Patient Information

Provide basic information for documentation:

• Last name

• First name

• Middle name

• Suffix (optional)

• Birthday

• Sex

• Civil Status

• Nationality (optional)

• Email

Current Address

Provide the following details:

• Province

• City

• Barangay

• House number or building/subdivision

• Street name

• Postal code (optional)

• Notable nearby landmarks (optional)

The region will automatically update itself once you have chosen your province.​

Permanent Address

If your Current Address and Permanent Address are the same, kindly click the box next to “Same as address (current).”If your permanent address is different from your current address, fill up the form with the required information:

• Province

• City

• Barangay

• House number or building/subdivision

• Street name

• Postal code (optional)

• Notable nearby landmarks (optional)

Patient Vaccination Record (optional)

Provide information of your vaccination status (if any).

If the patient has received vaccination, 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 Profile Photo (optional)

This is an optional field for some laboratories but there are laboratories that would need this for verification.

Identity Document

You may choose to use any of the following:

• Barangay ID

• Driver’s License

• Overseas Filipino Worker (OFW) ID

• Others

• PAG-IBIG

• Passport

• Philhealth ID

• Postal ID

• Philippine Regulations Commissions (PRC) ID

• Person With Disability (PWD) ID

• Senior Citizen ID

• Social Securtiy System (SSS) UMID Card

• Student

• Tax Identification Nunmber (TIN) Card

• 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 ID (optional)

Click the checkbox if you are a person with a disability and input your ID details.

This is an optional field. Fill this up in case the laboratory might need to prepare to give proper assistance during the laboratory visit.

Phone Number

Provide a phone number in case the laboratory would need to get in touch with you.

Declaration and Data Privacy Consent

This is to ensure the patients that the information provided will only be used by the lab.