COVID-19 Vaccine
Pre-Registration Form

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.

Personal Information

Address Information

Other Information

Employment Information

Screening Questions


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