COVID-19 Vaccine Pre-Registration

Consent for Use and Disclosure of Personal Data

I am giving my consent to The Medical City South Luzon to collect and process my personal data for COVID-19 Vaccination Program in accordance with the provisions of Data Privacy Act of 2012.

I understand that the declared purpose of the processing of my personal data is to establish a masterlist of eligible population for vaccination to enable health authorities to decide on who can be safely vaccinated from a clinical perspective.

I further understand that after immunization, the LGUs as well as the private sector are likewise required to submit the masterlist of persons who have already been inoculated through the VIMS-IR, subject to further guidance as may be issued by the DOH and the Department of Information and Communications (DICT).

On the issuance of vaccine cards, I understand that a standard form shall contain necessary information as prescribed by the DOH. I was assured that this vaccine card will not be given to anyone or posted publicly, and that I will be able given an electronic copy of my vaccine card only through the email address that I provided.

I am also assured by the collector that they have installed appropriate physical, organizational, and technical security measures to ensure that my personal data are protected.

I have read and agreed to this Privacy Notice and Consent *

Personal Information

Employee/Dependent?*

Employee

Dependent

Household

Name of Employee/Principal*

Employee ID Number*

Relation*

Firstname*

Middlename

Lastname*

Suffix*

Civil Status*

Gender*

Birthday (mm/dd/yyyy)*

Age*

Indigenous Member*

Height (cm)*

Weight (kg)*

Contact Number*

Email Address*

Address Information

Region*

Province*

Municipality/City*

Barangay*

Unit/House No., Street Name*

Other Information

Category*

Other Category(please specify)*

Category ID*

Other ID(please specify)*

Category ID number*

Philhealth Number (PIN)

PWD*

Employment Information

Profession*

Employment Status*

Other(please specify)*

Name of Employer*

Contact Number of Employer*

Address of Employer (e.g. street, block, lot, unit, barangay, city) *

Consent

I do hereby declare that all the information given above is true to the best of my knowledge and belief.
By submitting this form, you confirm that you have read and agree to Privacy Notice and Consent

For any of your questions and concerns, please call (049)-303-3000.

Signature *

Clear

I agree to the statement above

Please fill up all required field with (*) mark

#TMCSLCares

COVID-19 Vaccine

Pre-Registration Form