regform – Steadfast

Patient Registration Form

EMAIL:	Last Name:
First Name:	Middle Name/Initial:
BIRTHDATE:	AGE:
GENDER: Male Female Prefer not to say	Civil Status: Single Married Widowed Separated
Address:
Contact Number: Note: No spaces or special characters on the phone number Note: For landline numbers, just input the 7 digit phone number
FB/Instagram (please enter your Facebook/Instagram name): *If you prefer to be contacted thru phone instead, please enter your phone number. Please make sure you can be reached in the number or social media name you have entered, so we can provide updates with your schedules.
Referral:
LOCATION:	SERVICE: Note: Home Care Service only applicable for Cash payments.
CHIEF COMPLAINT:
PAYMENT METHOD: Cash GCash Bank Online Transfer HMO Credit or Debit Card

HMO:
Amaphil AsianCare Carewell Cocolife CoopHealth Dynamic Care Corp Eastwest Health Care Etiqa Forticare Generali GetWell HMI HPPI	In Life / Insular Life / Icare Kaiser Lacson Lacson Life and Health Med Asia Medicard Medicare Plus Pacific Cross Sunlife Grepa Valucare WellCare Other
HMO Card Number: **Note: No special characters or spaces. Only numbers and letters are allowed. Example: 1100223455678899 or AA11234567890
HMO ID/Policy Number: Note: No special characters or spaces. Only numbers and letters are allowed. Example: 1100223455678899 or 1234567890 Note: For Valucare/Cocolife/HMI/Eastwest/Insular HMO, please input the ID Number instead of the Card number (usually found at the bottom of the card). For other HMO provider, please input None*
Primary Card Holder: **Note: referred to as the primary card holder or person responsible for paying health insurance. For example, if the Wife is the Patient and her health insurance benefits are covered under her Husband's employment, then the Husband is the “Primary card holder.”
Company (if paying through HMO):
Occupation (position in the company):
Valid ID Type:
Passport Drivers License Philhealth ID SSS UMID PAGIBIG ID Postal ID PWD ID	TIN ID Voters ID PRC ID Senior Citizen ID Student ID OFW ID National ID Company ID
ID Number:

How do you rate your pain?Note: Adjust pain scale from 1-10. 1 being the least and 10 being the most painful.

5

Acquired through accident:
YES
NO
When did your complain/concern started:

Data Privacy:

We value your privacy and are committed to protecting your personal information. By submitting this form, you consent to the collection, use, and disclosure of your personal data in accordance with our Privacy Policy. Your information will be used solely for the purpose of providing and managing your healthcare services and will only be shared with your HMO providers as necessary.

I agree to the Data Privacy Act and consent to the collection and use of my personal data as described above.