SEHI- APPOINTMENT SYSTEM

Firstname *

Middlename

Lastname *

Suffix

Birth Date *

Age *

Gender *

Verify

Civil Status *

Nationality *

Religion

Country *

Region *

Province *

City *

Barangay *

Street

Zip Code *

Mobile No. *

Email Address *

Occupation

Doctor *

Specialist

Date *

Available Time *

	Name	Specialization

Are you the Patient's Representative ? *

Yes

Patient/Reprentative *

Relationship

The processing, collection, use, storing, sharing and disclosing of your Personal and Sensitive Personal Information by SEHI, its subsidiaries, agents, authorized service providers, and marketing partners for purposes of contacting you about products and services marketed by SEHI. You can refuse the consent to this clause by unchecking the box

I authorize and consent to SEHI’s use of password protected e-mail/s to communicate with me, which e-mails may contain my or my Contact’s Personal Information and my Sensitive Personal Information, especially information relating to my medical condition.

I authorize SEHI to use password protected e-mail/s to communicate with me or my Contact for matters not containing my Personal Information and/or Sensitive Personal Information

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