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)