Home Health Care || Contact Us

Thank you for choosing to apply for your very own RxPinoy Wish card. Kindly Complete the form below.

Name of Principal

Last Name:

First Name:

Middle Name:

Home Address

Contact me here

Building/Floor

House No./Street

Baranggay/Village

Town/City

Phone(s), Landline(s)

COMPANY/Building/Floor

Contact me here

No./Street

Baranggay/Village/District

Town/City/COUNTRY

Phone(s), Landline(s)

Personal & Contact Details

Sex

Civil Status

Mobile Phone

Primary Email

Confirmation

I affirm that above given information is true, correct and updated. I hereby authorize RxPinoy WiSH to verify such information for whatever cause it may consider appropriate. I confirm that I have read, understood and agreed to the terms and conditions governing the issuance and use of the RxPinoy WiSH card as evidenced by my signature at right.

In-Case-of-Emergency (ICE) Alert Information

This optional function allows your critical health data to be retrievable via SMS special access numbers using the mobile number of the Principal.

Check here if you would like to avail of this feature

Primary care doctor and their hosp./clinic

Person to be contacted in case of emergency:
Name

Relationship

Mobile

Landline

Address

Blood Type:
A B AB O

Known Allergies

Existing Condition/s (e.g., diabetes)

Implant/s (e.g., pacemaker)

Current medications (if any)

Statement of Consent for the Disclosure of Personal Medical Data

I hereunto affix my signature at right to signify that I have freely given my unambiguous consent for the collection of the personal data I have disclosed above and agree to the data processing /storage/hosting of the same by RxPinoy WiSH. That the above personal medical information shall be used solely for my medical benefit for the In-Case-of-Emergency (ICE) data feature of RxPinoy WiSH. RxPinoy WiSH shall ensure at all times the protection of the above personal medical data with regard to privacy, confidentiality, content control, and, under appropriate circumstances, anonymity.

Verify security code

Type security code here:

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