Client Information

First Name

Last Name

Middle Name

Date of birth


Gender
GenderMaleFemale
Contact Number

Email

Provided By

Relation to Patient

Reservation Information

Room Type
Select a RoomVIP/Suites RoomPrivate Premium RoomNewly Renovated Private RoomPrivate Regular RoomSemi-Private RoomWard RoomIntensive Care Unit (ICU) Room
Doctor’s Name

Reservation Date

Mode of Payment
Mode of PaymentHMOPrivateCash
Document (Physician’s Order, Letter of Authorization(LOA), Any valid ID of patient )

Patient ID

Reservation Type
ReservationECUWALK INOR
Remarks (optional)