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Makati COVID-19 Vaccine

Your reservation for COVID-19 Vaccine has been

Makati COVID-19
successfully saved.
Please save your confirmation number.
Vaccination
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Pre-reservation

Notes:
Okay
For optional fields (without *) leave blank if not
applicable
Patients who were tested positive for COVID 19 may
register upon full recovery.
Patients who have symptoms stated in the screening
questionnaire are recommended to seek consultation
at their respective health center and self-quarantine
for 14 days prior to reapplying for registration
Patients who have received previous vaccinations
may register a!er 4 weeks from the date of the last
immunization
Please place correct mobile number. Your schedule
will be sent to your mobile number via SMS.
Ensure that you provide your full name (first, middle
and last name) consistent with o"icial documents
such as birth certificate or travel passport.

Non-Makati LGU Vaccinated Individuals

Basic Information
First Name * :
Arthur

Middle Name * :
Basilio

Last Name * :
Santos

Su"ix Name :
-- Select Su"ix --

Sex *
Male Female

Birthdate * :
May 18, 1948

Civil Status * :
Separated/Annulled

Email:

Mobile No. * :
09178862930

Profession *:
Others

Copy of Vaccination Card *:

Choose File no file selected

Working in Makati City Hall?*

Yes No

Are you getting vaccinated in any private vaccination sites?*

Yes No

Employer Name :

Employer Province :

Employer Address :

Employer Contact No :

Current Address
Region * :
National Capital Region

Province * :
NCR, FOURTH DISTRICT (Not a Province)

City * :
CITY OF MAKATI

Barangay * :
BEL-AIR

Street * :
Tordesillas

Bldg. Name :
Le Domaine

House/Unit No. * :
U 1601

Screening Questionaire for

Vaccination
For eligible individuals to be vaccinated, the following questions
will help us determine if there is any reason, we should not give
you vaccination today. If you answer "Yes" to any questions, it
does not necessarily mean you should not be vaccinated. It just
means additional questions must be asked .If a question is not
clear, please ask your health care provider to explain it.

English Filipino

Question

Have you (or any family

member/s) been Not Yes No
diagnosed with or tested Sure
positive for COVID-19 in the
past three (3) months?

Do you or have you the following symptoms in the

past 14 days?

- fever of greater
than 37.5°C Not Yes No
Sure

- Do you or have
you had any 'flu- Not Yes No
like' symptoms, Sure
such as cough or
chills, in the past
14 days?

- Do you
experience Not Yes No
shortness of Sure
breath or
breathing
di"iculty?

- Do you have any

di"iculties with Not Yes No
your sense of taste Sure
or smell at
present?

- headache,
muscle or body Not Yes No
ache Sure

- weakness or
fatigue Not Yes No
Sure

- Are you
experiencing Not Yes No
diarrhea? Sure

Do you have any allergy to

food, antibiotics, or any Not Yes No
medicine? Sure

Have you ever had a severe

reaction to vaccines in the Not Yes No
past? Sure

Have you received any

vaccine in the last 14 days? Not Yes No
Sure

For women;

- Are you pregnant

Not Yes No
Sure

- For women who

are pregnant, are Not Yes No
you in your 1st Sure
trimester (1 to 3
months) of
pregnancy?

- Plans to get
pregnant in the Not Yes No
next 6 months? Sure

Do you have a bleeding

disorder or are you taking a Not Yes No
blood thinner? (Example of Sure
Bleeding disorder:
Hemophilia, Thalassemia)
(Example of blood thinning
medications: Aspirin,
Clopidogrel, Warfarin,
Cilostazol)

Do you have any of the following illness/disease?

- Autoimmune
disease Not Yes No
Sure

- HIV Diagnosis
Not Yes No
Sure

-
Cancer/Malignancy Not Yes No
Sure

- Transplant
Patient Not Yes No
Sure

- Under steroid
treatment Not Yes No
Sure

- Bed ridden,
terminal illness, Not Yes No
less than 6mos Sure
prognosis

Are you bedridden?

Not Yes No
Sure

Are you wheelchair bound?

Not Yes No
Sure

Note: If you answered yes to any of the above-mentioned

diseases/condition, please provide a medical clearance
from your physician on the day of your vaccination.

Category *:
Senior Citizen

Category ID*:
OSCA number

Category ID No * :
40288

Philhealth ID :

PWD ID :

Employment Status * :
Others

Directly in interaction w/ COVID Patient? *

Yes No

Allergies (Please check all that apply):

Drug Allergy Food Allergy Insect Allergy
Latex Allergy Mold Allergy Pet Allergy
Pollen Allergy

With Co-morbidities? *
Yes No

Was diagnosed with COVID-19?*

Yes No

Please make sure you have reviewed all answers and

uploaded all necessary documents, if any. No changes shall
be possible a!er submission.
I have reviewed my reply and uploaded the correct
documents and attest that they are all correct.

Submit