COVID-19 Vaccine Pre-Registration

Please fill with your details

Inputs with RED icons/text are REQUIRED.

ARE YOU WILLING TO BE VACCINATED?

Client Address

Employer Details

Work requires direct interaction to covid19 patient?
Yes No

Pregnancy Status
Yes No

Allery Status Yes All No All

Drug Allergy? Yes No

Food Allergy? Yes No

Insect Allergy? Yes No

Latex Allergy? Yes No

Mold Allergy? Yes No

Pet Allergy? Yes No

Pollen Allergy? Yes No

With Comorbidity Yes All No All

Hypertension? Yes No

Heart Disease? Yes No

Kidney Disease? Yes No

Diabetes? Yes No

Asthma? Yes No

Immunodeficiency? Yes No

Cancer? Yes No

Others? Yes No

Diagnosed With Covid19? Yes No

Provide Electronic Consent?

I hereby authorize the Municipality of Los Baños Laguna, to collect my personal data supplied herein for the purpose of effective control of the COVID-19 transmission. I understand that it is protected by RA 10173, otherwise known as the "Data Privacy Act of 2012", and that I am required by RA 11469, otherwise known as the "Bayanihan to Heal as One Act", to provide truthful information.

LB RESBAKUNA

KAYO PO AY REHISTRADO NA SA LB RESBAKUNA. MANGYARING HINTAYIN NA LAMANG PO ANG INYONG SCHEDULE. ITO PO AY IPAPADALA SA NUMERO NA INYONG INIREHISTRO.

LB RESBAKUNA

First Name

Middle Name

Last Name

Contact Number

Sex

Date Registered

Address

For your clarifications and concerns you may reach the Information and Communication Systems Office through:

Facebook Page: MGLB ICSO

E-mail: icso@losbanos.gov.ph

Land Line: 530-2952 Local 103

Confirm Birthday:

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