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
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Birthdate
FEMALE
MALE
Gender
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MARRIED
UNMARRIED
WIDOW
Civil Status
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Nationality
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Afrikaans
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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
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CHINESE
COLOMBIAN
CONGOLESE
CROATIAN
CUBAN
DANISH
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DUTCH
ECUADORIAN
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ETHIOPIAN
FIJIAN
FILIPINO
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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
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PAPUAN
PARAQUAYAN
PERUVIAN
PORTUGUESE
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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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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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Algeria
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Antarctica
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Argentina
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Australia
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Chile
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Eritrea
Estonia
Ethiopia
Falkland Islands
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Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Guinea
Guinea-Bissau
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Laos
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Myanmar
Namibia
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Netherlands
Netherlands Antilles
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Niue
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Northern Mariana Islands
Norway
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Others
Pakistan
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Palestine
Panama
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Paraguay
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Philippines
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Reunion
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Vanuatu
Vatican
Venezuela
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Wallis and Futuna
Western Sahara
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Address
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ROMAN CATHOLIC
MUSLIM
BUDDIST
CHRISTIAN
HINDU
OTHERS
Religion
Next of Kin / Relationship
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