LPDH Home Care Program Request Form

Please be reminded that this online request form is for patients age of 18 years and below.

For adults and seniors, please be directed by clicking here.

For patients previously enrolled in a Home Care Package and wants to continue with a new Home Care package, please click here.

After completion of this form, the patient will be automatically assigned to one of our Home Care doctors.

PATIENT INFORMATION

Do you have an endorsement from a Home Care physician from LPDH? *

Endorsement from a Home Care physician, if any: *

Please state name of Home Care physician and endorsement

Full Name *

First Name Middle Name Last Name

Date of Birth *

Day Month Year

Sex *

Age

Current

Date

Mobile Number *

Home Number *

Address *

Street Address

Street Address Line 2

City

E-mail *

Second E-mail, if any

example@example.com

Third E-mail, if any

example@example.com

GUARDIAN INFORMATION

Guardian's Name *

First Name Last Name

Relationship to patient *

Guardian's Date of Birth *

Date

Mobile Number *

Home Number *

Children with special needs

Autism Attention deficit hyperactivity disorder (ADHD) Cerebral Palsy Intellectual disabilities

Musculo Skeletal Disorder

Dysplasia Osteogenesis imperfecta

Blood Disorder

Hemoglobinopathies Thalassemia Hemophilia

Congenital Conditions

Congenital heart disease-cyanotic/acyanotic Cleft lip/cleft palate

Newborn

Sepsis Prematurity

Infection

Active TB Human immunodeficiency virus (HIV) Acquired Heart disease

Respiratory Problems, Non-Infectious

Bronchial Asthma

Renal Disorder

Acute Renal Failure Chronic Renal Failure

Collagen Vascular Disorder

Rheumatic dses Systemic lupus erythematosus (SLE) Juvenile rheumatoid arthritis (JRA) Henoch-Schonlein purpura (HSP)

Nutrition Disorder

Malnutrition, severe Obesity Anorexia nervosa

Endocrine

Diabetes mellitus

Others

Hypertension Renal problem Vascular problem Malignancy Seizure disorder Mental disorder Other, please speciy

Have you taken an RT-PCR swab test? *

Yes No

Date of last RT-PCR

Date

Location of RT-PCR facility

Please enter the location of the facility from your last RT-PCR swab

Result of RT-PCR swab

HOME CARE PACKAGE OPTIONS

Package A (1 Day) Price: PHP 7,600
Package B (3 Days) Price: PHP 15,800
Package B Plus (Additional 10 Days) Price: PHP 16,500
Package C (7 Days) Price: PHP 18,500
Package C Plus (Additional 7 Days) Price: PHP 12,900
Package D (14 Days) Price: PHP 29,500

Home Care Package *

Please select a Home Care Package

Preferred platform for video consultation *

Payment Option *

On-Site Cash On-Site Credit Card GCash PayMaya Online Bank Transfer

Person with Disability

PWD ID Number

Image Copy of PWD ID

Browse Files

SUMMARY

{homeCare}

PHP {total}

TOTAL: PHP {totalWith}

With 20% PWD Discount

Total

Total with PWD Discount

PAYMENT INFORMATION

Please wait for your confirmation to be sent to your email. You will also receive a copy of your online request right after your submission.

For cash and credit card payments, please proceed to the LPDH Emergency Room for processing of payment and for the tests included in your package. Please show your e-mail confirmation of your Home care Package.

For your safety, convenience and for a faster service, we recommend that payment be made in advance through GCash or Online Bank Transfer.

PAYMENT INFORMATION

GCASH

Account Number: 0927 472 1007

We will be providing a copy of your request through your e-mail right after the completion of this online form.

PAYMENT INFORMATION

PayMaya

Account Number: XXXXXXXXXXXX

We will be providing a copy of your request through your e-mail right after the completion of this online form.

PAYMENT INFORMATION

Philippine National Bank (PNB)

Account Number: 145170007407
Account Name: Las Piñas Doctors Hospital, Inc.

We will be providing a copy of your request through your e-mail right after the completion of this online form.

Upload Screenshot/Proof of Payment *

Browse Files

WAIVER FOR LPDH HOME CARE PROGRAM

I, First Name* Last Name*, was a COVID-positive/probable/suspect patient. I decided to avail the Home Care Package of Las Pinas Doctors Hospital (“LPDH”) which includes: Specify Home Care Package*.

I acknowledge that the Home Care Package is a purely virtual service provided by LPDH to cater to the needs of Covid-suspect, -probable or -positive mild patients at the comfort of the patient’s home wherein I shall guarantee excellent wifi connection for ease and uninterrupted communication with my doctor. I further acknowledge that availing the Home Care Package shall not guarantee my recovery since Covid-19 has no known cure and admission in LPDH if capacity of Covid ward is full should my condition worsen, and shall not be grounds for any claim against LPDH, its doctors, and staff. LPDH does not have any obligation to look for another hospital if I may need admission. I also have the right to seek consultation in another hospital with another doctor anytime.

I am allowing LPDH to use my information provided in the online form within the different departments of the hospital likewise share to any third-party contractors that are involved in my treatment and availment of the program. Likewise, I am granting permission that my laboratory and diagnostic results be sent via e-mail.

Additional fees will be incurred if ambulance conduction (upon availability of schedule) and medications will be needed. I understand that reimbursement and cancellation of availment of package are not allowed. The enrolment in the Home Care Package is purely of my own volition and i was not forced by any one from lpdh to avail of the same.
I hereby release and discharge LPDH, its doctors, and its staff from any and all liabilities, injuries, or death arising from or in relation to my availment of the Home Care Package of LPDH.

*

I hereby acknowledge that I have completely read and fully understood this waiver