PATIENT REGISTRATION
Full Name
Please put your complete name and correct birthday if you are the patient as your record will be used in the prescription.
Email
Mobile Number
Birthdate
FEMALE
MALE
Gender
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MARRIED
UNMARRIED
WIDOW
Civil Status
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Afghan
Albanian
Algerian
American
Andorran
Angolan
Antiguans
Argentinean
Armenian
Australian
Austrian
Azerbaijani
Bahamian
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East Timorese
Ecuadorean
Egyptian
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Eritrean
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Filipino
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French
Gabonese
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German
Ghanaian
Greek
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Mongolian
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Swazi
Swedish
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Venezuelan
Vietnamese
Welsh
Yemenite
Zambian
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Nationality
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Afrikaans
Albanian
Amharic
Arabic
Armenian
Azerbaijani
Basque
Belarusian
Bengali
Bikol
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Catalan
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Dutch
English
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Irish
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Karay-A
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Polish
Portuguese
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Language
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AFGHAN
AFRICAN
ALBANIAN
ALGERIAN
AMERICAN
ANDORRAN
ANGOLAN
ARMENIAN
AUSTRALIAN
AUSTRIAN
AZERBAIJAN
BAHAMIAN
BANGLADESHI
BARBADIAN
BELIZEAN
BHUTANI
BOLIVIAN
BOSNAI AND HERZEGOVINA
BRAZILIAN
BRITISH INDIAN OCEAN TERRITORY
BRUNEIAN
CAMBODIAN
CAMEROONIAN
CANADIAN
CAUCASIAN
CHADIAN
CHILEAN
CHINESE
COLOMBIAN
CONGOLESE
CROATIAN
CUBAN
DANISH
DOMINICAN
DUTCH
ECUADORIAN
EGYPTIAN
ETHIOPIAN
FIJIAN
FILIPINO
GABONESE
GAMBIAN
GEORGIAN
GERMAN
GHANAIAN
GUATEMALAN
HAITIAN
HONDURAN
HUNGARIAN
ICELANDIC
INDIAN
INDONESIAN
IRANIAN
IRISH
ITALIAN
IVORIAN
JAMAICAN
JAPANESE
JORDANIAN
KENYAN
KOREAN (NORTH)
KOREAN (SOUTH)
KYRGYZ
LAOTIAN
LATVIAN
LEBANESE
LIBERIAN
LIBYAN
LITHUANIAN
MALAWIAN
MALAYSIAN
MALDIVIAN
MALIAN
MALTESE
MARSHALLESE
MAURETANIAN
MEXICAN
MICRONESIAN
MONGOLIAN
MOROCCAN
MOZAMBICAN
NEPALESE
NEW ZEALANDER
NICARAGUAN
NIGERIAN
NORWEGIAN
OMANI
OTHERS
PAKISTANI
PALESTINIAN
PANAMANIAN
PAPUAN
PARAQUAYAN
PERUVIAN
PORTUGUESE
ROMANIAN
RUSSIAN
SAMOAN
SENEGALESE
SIERRA LEONEAN
SINGAPOREAN
SOUTH AFRICAN
SPANISH
SRILANKAN
SUDANESE
SYRIAN
TAIWANESE
TANZANIAN
THAI
TOGOLESE
TUNISIAN
TURKMENISTAN
UGANDAN
UKRAINIAN
URUGUAYAN
VENEZUELAN
VIETNAMESE
ZAMBIAN
ZIMBABWEAN
Culture
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N/A
Primary Education
Secondary Education
Undergraduate / Any 4 year Course Degree
Postgraduate Degree
Doctoral Degree
Educational Attainment
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Chronic Illness
Hearing Loss
Learning Disability
Mental Disability
Orthopedic Disability
Others
Paraplegia
Psychosocial Disability
Visual Impairment
Disability Type (Applicable for PWD only)
Occupation/Profession
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ABRA
AGUSAN DEL NORTE
AGUSAN DEL SUR
AKLAN
ALBAY
ANTIQUE
APAYAO
AURORA
BASILAN
BATAAN
BATANES
BATANGAS
BENGUET
BILIRAN
BOHOL
BUKIDNON
BULACAN
CAGAYAN
CAMARINES NORTE
CAMARINES SUR
CAMIGUIN
CAPIZ
CATANDUANES
CAVITE
CEBU
COMPOSTELA VALLEY
COTABATO (NORTH COTABATO)
DAVAO DEL NORTE
DAVAO DEL SUR
DAVAO OCCIDENTAL
DAVAO ORIENTAL
DINAGAT ISLANDS
EASTERN SAMAR
GUIMARAS
IFUGAO
ILOCOS NORTE
ILOCOS SUR
ILOILO
ISABELA
KALINGA
LA UNION
LAGUNA
LANAO DEL NORTE
LANAO DEL SUR
LEYTE
MAGUINDANAO
MARINDUQUE
MASBATE
METRO MANILA
MISAMIS OCCIDENTAL
MISAMIS ORIENTAL
MOUNTAIN PROVINCE
NEGROS OCCIDENTAL
NEGROS ORIENTAL
NORTHERN SAMAR
NUEVA ECIJA
NUEVA VIZCAYA
OCCIDENTAL MINDORO
ORIENTAL MINDORO
OTHERS
PALAWAN
PAMPANGA
PANGASINAN
QUEZON
QUIRINO
RIZAL
ROMBLON
SAMAR (WESTERN SAMAR)
SARANGANI
SIQUIJOR
SORSOGON
SOUTH COTABATO
SOUTHERN LEYTE
SULTAN KUDARAT
SULU
SURIGAO DEL NORTE
SURIGAO DEL SUR
TARLAC
TAWI-TAWI
ZAMBALES
ZAMBOANGA DEL NORTE
ZAMBOANGA DEL SUR
ZAMBOANGA SIBUGAY
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-- Country* --
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
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Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
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Burundi
Cambodia
Cameroon
Canada
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
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Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
North Korea
Northern Mariana Islands
Norway
Oman
Others
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
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Singapore
Sint Maarten
Slovakia
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Tanzania
Thailand
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Tokelau
Tonga
Trinidad and Tobago
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Turkey
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Turks and Caicos Islands
Tuvalu
U.S. Virgin Islands
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Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Address
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ROMAN CATHOLIC
MUSLIM
BUDDIST
CHRISTIAN
HINDU
OTHERS
Religion
Next of Kin / Relationship
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