Patient Registration
Fill out the form below
Complete the form to generate your medical QR code.
First Name
Last Name
Sex
Male
Female
Date of Birth
Contact Number
Citizen ID
SSS ID
Philhealth ID
Address
Street Address
Region
Select Region
REGION I (ILOCOS REGION)
REGION II (CAGAYAN VALLEY)
REGION III (CENTRAL LUZON)
REGION IV-A (CALABARZON)
REGION IV-B (MIMAROPA)
REGION V (BICOL REGION)
REGION VI (WESTERN VISAYAS)
REGION VII (CENTRAL VISAYAS)
REGION VIII (EASTERN VISAYAS)
REGION IX (ZAMBOANGA PENINSULA)
REGION X (NORTHERN MINDANAO)
REGION XI (DAVAO REGION)
REGION XII (SOCCSKSARGEN)
NATIONAL CAPITAL REGION (NCR)
CORDILLERA ADMINISTRATIVE REGION (CAR)
AUTONOMOUS REGION IN MUSLIM MINDANAO (ARMM)
REGION XIII (Caraga)
Province
Select Province
Municipality/City
Select Municipality
Barangay
Select Barangay
Generate QR Code