TrueMed - PhilHealth YAKAP GAMOT Availment Form

1 Patient Information

Last Name*

Last name is required.

First Name*

First name is required.

Middle Name*

Middle name is required.

Walk In / Company / Group*

Please select an option.

2 Patient Consent

3 Prescription

UPSC Code*

UPSC code is required.

Prescription Photo*

Tap to choose file

Issued by a licensed physician - PDF, JPG or PNG

Prescription photo is required.

4 Valid Identification (Member)

ID Type*

Select an ID type.

Upload Valid ID*

Tap to choose file

JPG, PNG or PDF - both sides if applicable

A valid ID is required.

5 Patient Signature

Sign below*

Draw your signature here

Signature is required.

6 Delivery Address

Contact Number*

Enter a valid contact number.

Street Address*

Street address is required.

City*

City is required.

ZIP Code*

ZIP code is required.

Region*

Select a region.

Landmark

Delivery Notes

Uploading...

Your data is encrypted and stored securely under R.A. 10173.

Done

Documents Submitted

Your documents are under review.
A TrueMed representative will reach out within 1-2 business days.