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COVID VACCINE REGISTRATION FORM

Last Name
First Name
Middle Name
Name Suffix (Jr, Sr, etc.)
Barangay Name
Barangay Zone
Gender
Birth Date
Civil Status
Contact Number
Are you Pregnant? (Answer No if Male)
Occupation
Directly Interacting with COVID Patients?
Have Drug Allergy?
Have Food Allergy?
Have Insect Allergy?
Have Latex Allergy?
Have Mold Allergy?
Have Pet Allergy?
Have Pollen Allergy?
With Comorbidity?
Have Hypertension?
Have Heart Disease?
Have Kidney Disease?
Have Diabetes?
Have Asthma?
Have Immune Defeciency?
Have Cancer?
Other Disease/s
Were you diagnosed with COVID-19?
If yes, Indicate Date of Positive Result.
If yes, Indicate the Classification of COVID-19
Are you willing to be Vacinated?