Batangas City COVID-19 Vaccination Pre-Registration

Personal Information

Last Name

First Name

Middle Name

Suffix

Birthdate:

Sex

Civil Status

Current Residence(house #,building,street)

Barangay

Mobile Number

Email address

Sector

Proof of Identification

ID Number

Upload ID (image files only)

PhilHealth ID Number

PWD ID Number

Work Information

Employment Status

Profession

Employer

Employer's Province/HUC/ICC

Employer's Address

Employer's Contact Number

Health Information

I have drug allergy

I have food allergy

I have insect allergy

I have latex allergy

I have mold allergy

I have pet allergy

I have pollen allergy

I have kidney disease

I have immunodeficiency

I have hypertension

I have cancer

I have heart disease

I have diabetes

I have tuberculosis

I am pregnant

Do you have any Other Diseases?

Other Disease

Have you ever tested positive for COVID-19?

If YES, indicate the date when you became positive to COVID-19, otherwise leave blank

COVID-19 Classification

Do you want to be vaccinated?

Vaccine Preference

Available Vaccine

I have read and agreed to the Data Privacy Consent

Batangas City

COVID-19 Vaccination Pre-Registration

33328Total Pre-Registered

Personal Information

Work Information

Health Information

33328
Total Pre-Registered