Vaccination Form

PRIORITY GROUP *

FIRST NAME *

Pangalan

LAST NAME *

Apilyido

MIDDLE NAME *

SUFFIX *

CONTACT NUMBER *

WAG ILAGAY ANG 0, MAGSIMULA SA 9. EX: 917 123 4567

CURRENT RESIDENCE REGION *

CURRENT RESIDENCE PROVINCE *

CURRENT RESIDENCE MUNICIPALITY/CITY *

CURRENT RESIDENCE BARANGAY *

CURRENT RESIDENCE *

Unit/Building/House Number Street Name

SEX *

Female Male

BIRTHDATE *

CIVIL STATUS *

OCCUPATION *

WITH COMORBIDITY *

Yes None

ALLERGY TO VACCINES OR COMPONENTS OF VACCINES *

Yes No

DIRECTLY IN INTERACTION WITH COVID PATIENT *

Yes No

PATIENT WAS DIAGNOSED WITH COVID 19 *

Yes No

DATE OF FIRST POSITIVE RESULT / SPECIMEN COLLECTION

Date

Palatuntunan sa pag punta sa vaccine area.

A. Para sa A2, kung senior ka.

Dapat meron ka 1 govt ID na nandun ang birthdate mo.

B. Para sa A3, kung comorbid ka.

Siguruhin may receta ka ng maintenance mo ganun din kung may ashma. Or doctors certificate with licence no. na nag papatunay na may ashma ka.

C. Para sa A4, kung frontline personnel in esaential sector ka.

Pakita mo ID mo at certificate ng dept head mo. With xerox ID ng head.

D. Magdala ng sariling ballpen, facesheild at facemask.

E. Kung saan na vaccination center ikaw nagpaturok ng 1st dose ay doon karin magpaturok sa 2nd dose mo.

VACCINATION FORM