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REGISTRATION

PhilHealth Client Type:
Member

First Name:

Date of Birth (dd/mm/yyyy):

PhilHealth ID Number:

Middle Name:

Phone Number:

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Last Name:

Email

Date required

Name Extension (Jr./Sr./III):

Sex:

Male

Female

I agree to the Data Privacy & Terms of UseData Privacy & Terms of Use

I choose TeleCure as my Primary Care Provider

Your Signature

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