Patient Registration
Mhavis Medical & Diagnostic Center
Patient Type
New Patient
- I am registering for the first time
Existing Patient
- I have been treated here before
Personal Information
First Name
*
First name cannot contain numbers.
Middle Name
Middle name cannot contain numbers.
Last Name
*
Last name cannot contain numbers.
Suffix
Select Suffix (Optional)
Jr.
Sr.
II
III
IV
Date of Birth
*
Sex
*
Select Sex
Male
Female
Civil Status
*
Select Civil Status
Single
Married
Divorced
Widowed
Separated
Senior Citizen
Warning:
Senior Citizen ID Number
*
ID Attachment
*
Upload a picture of yourself holding your Senior Citizen ID, or upload a clear picture/scan of your ID card. Accepted formats: JPG, PNG, GIF, PDF (Max 5MB)
Person with Disability (PWD)
PWD ID Number
*
ID Attachment
*
Upload a picture of yourself holding your PWD ID, or upload a clear picture/scan of your ID card. Accepted formats: JPG, PNG, GIF, PDF (Max 5MB)
Contact Information
Phone Number
*
+63
Enter 10 digits only (e.g., 9123456789). Country code +63 is fixed.
Email Address
*
Address
*
Region
*
Select Region
Province
*
Select Province
City/Municipality
*
Select City
Barangay
*
Select Barangay
Emergency Contact
Emergency Contact Name
*
Emergency contact name cannot contain numbers.
Relationship to Emergency Contact
*
Select Relationship
Spouse
Parent
Child
Sibling
Friend
Guardian
Other
Emergency Contact Phone
*
+63
Enter 10 digits only (e.g., 9123456789). Country code +63 is fixed.
Medical Information
Blood Type
*
Select Blood Type
A+
A-
B+
B-
O+
O-
AB+
AB-
Known Allergies
Chief Complaint
Describe your primary health concern or reason for this visit.
Account Information
For security, your password will be automatically generated by the system and included in the approval email. You will log in using your Patient ID and this password. Please change it after your first login.
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