UCMed Online PCR(Swab) Test Registration
Appointment Schedule
Please fill in required fields *
Transaction Type *
Walk-In
Drive-Thru
Home Service
Appointment Date *
Appointment Time *
Patient Information
Please fill in required fields *
First Name *
Middle Name
Last Name *
Suffix(Jr., Sr.,)
Date of Birth *
Sex from Birth *
Civil Status *
Nationality *
Occupation *
Are you a Philhealth Member? *
No
Yes
Philhealth Identification Number (PIN)
Purpose of Testing *
Travel
Diagnostic
Work Requirement
Others
Specify
Current Address & Contact Information
Please fill in required fields *
House No./Lot/Bldg. *
Street/Purok/Sitio *
Province *
Municipality/City *
Barangay *
Home Phone No.(& Area Code)
Email Address *
Mobile No.*(Format: 09123456789)
Employment & Contact Information
Please fill in required fields *
Lot/Bldg. *
Street *
Barangay *
Municipality/City *
Province *
Name of Workplace
*
Landline/Mobile No.*
Email Address *
Permanent Address & Contact Information
Please fill in required fields *
House No./Lot/Bldg. *
Street/Purok/Sitio *
Province *
Municipality/City *
Barangay *
Home Phone No.(& Area Code)
Mobile No.*
Email Address *
Overseas Address & Contact Information
Please fill in required fields *
Check if Not Applicable.
House No./Lot/Bldg. *
Street *
Municipality/City *
Province *
Country *
Place of Work *
Employer's Name *
Employer's/Office Office Contact No. *
Admission & Consultation History
Please fill in required fields *
Did you have previous COVID-19 related consultation? *
No
Yes
Date of First Consultation
Name of facility where first consult was done
Was the case admitted in a health facility? *
No
Yes
Date of Admission
Name of facility where patient was first admitted
Region and Province of Facility
Disposition at Time of Report
Please fill in required fields *
Admitted in Hospital? *
No
Yes
Hospital Name
Date admitted in hospital
Time admitted in hospital
Admitted in isolation/Quarantine facility? *
No
Yes
Isolation/Quarantine Facility
Date Isolated/Quarantined in facility
Time Isolated/Quarantined in facility
In home isolation/quarantine? *
No
Yes
Date Isolated/Quarantined at home
Time Isolated/Quarantined at home
Discharged to home? *
No
Yes
Date Discharged
Others?
Health Status at Consult
Please fill in required fields *
Health Status at Consult
Not Applicable
Asymptomatic
Mild
Moderate
Severe
Critical
Special Population
Please fill in required fields *
Health Care Worker? *
No
Yes
Name and Location of health facility
Returning Overseas Filipino? *
No
Yes
Country of Origin
Foreign National Traveler? *
No
Yes
Country of Origin
Locally Stranded Individual/APOR/Traveler? *
No
Yes
Country of Origin
Lives in Closed Settings? *
No
Yes
Type of Institution
Clinical Information
Please fill in required fields *
Date of Onset Illness
Signs and Symptoms (Check all that apply if present)
Asymptomatic
Fever
Cough
General weakness
Fatigue
Headache
Myalgia
Sore throat
Coryza
Dyspnea
Anorexia
Nausea
Vomiting
Diarrhea
Altered Mental Status
Anosmia (loss of smell)
Ageusia (loss of taste)
Others
Comorbidities (Check all that apply if present)
Hypertension
Diabetes
Heart Disease
Lung Disease
Gastrointestinal
Genito-urinary
Neurological Disease
Cancer
Others
Are you pregnant?
No
Yes
Last Menstrual Period
High-risk pregnancy?
No
Yes
Laboratory History
Please fill in required fields *
Have you ever tested positive using RT-PCR before? *
No
Yes
Laboratory
Date of Specimen Collection
Number of previous RT-PCR swabs done *
Exposure History
Please fill in required fields *
History of exposure to known probable and/or confirmed COVID-19 case 14 days before the onset of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection
No
Yes
Unknown
Date of Last Contact
Have you been in a place with a known COVID-19 community transmission 14 days before the onset of signs and symptoms? OR if Asymptomatic, 14 days before swabbing or specimen collection?
No
Yes
Unknown Exposure
Date of Last Contact
IF Yes, specify place (Check all that apply, provide details such as name of establishment, transport service, venue, location etc. and date of visit)
Place Visited
Details
Date of Visit
Health Facility
Closed Settings
Market
Home
International Travel
School
Transportation
Work Place
Local Travel
Social Gathering
Others
Travel History
Please fill in required fields *
History of travel/visit/work in other countries with a known COVID-19 transmission 14 days before the onset of signs and symptoms
No
Yes
Country of Exit
Airline/Sea Vessel
Flight/Vessel Number
Date of Departure
Date of Arrival in PH
History of travel/visit/work in local place with a known COVID-19 transmission 14 days before the onset of signs and symptoms
No
Yes
Place of Origin
Airline/Sea Vessel/Bus line/Train
Flight/Vessel Number/Bus No.
Date of Departure
Date of Arrival in the current
List the names of persons who were with you two days prior to onset of illness until this date and their contact numbers.
*If asymptomatic, list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers.
Name
Contact Number
For Additional Close Contact (Include All Household Contacts)
Name
Contact Number
Exposure Setting
Vaccination Information
Please fill in required fields *
Were you able to receive a COVID-19 vaccine? *
No
Yes
Date of vaccination (Dose 1)
Name of Vaccine
Vaccination Center/Facility
Region of Health Facility
First Dose Adverse event/s? *
No
Yes
Date of vaccination (Dose 2)
Name of Vaccine
Vaccination Center/Facility
Region of Health Facility
Second Dose Adverse event/s? *
No
Yes
Review & Verify
Verify by ticking the checkbox *
Is this your name? *
Is this your current address? *
Is this your current email? *
Is this your current cellphone no.? *
Test
Test

Information: For Walk-In

There will be no specific appointment date allocated for walkin.
Monday to Saturday 8AM-12NN & 1PM-4PM.
Please proceed to Ground Floor, UCMed Medical Arts Bldg. to process your RT-PCR (Swab Testing).
Walk-in applications are in "First Come, First Served" basis.

Please complete the following registration form to avoid delay.
The data, illegibility & integrity of results will be your responsibility, any correction of incorrect information submitted will not be accommodated, you may submit another application instead.

Information: For DriveThru

Strictly "PAYMENT BEFORE PROCEDURE"

  1. After Registration, please send your registration code and a copy of your:
    --Proof of Payment
    --PAL Ticket(If Applicable)
    --Valid ID
    --SENIOR or PWD ID(If Applicable)
    to pcr@ucmed.ph.
  2. We will forward your proof of payment to our business office for verification.
    Once verified, we will send you the final confirmation of your appointment.


Please complete the following registration form to avoid delay.
The data, illegibility & integrity of results will be your responsibility, any correction of incorrect information submitted will not be accommodated, you may submit another application instead.

Information: For Home Service

*Please be advised that after registration, appointment is still subject for availability

  1. Please email the details below to homeservice@ucmed.ph.
    --Patient's Names (All patient names who will avail the service in your area).
    --Preferred Date
    --Address/Location (Include a Landmark if any)
  2. Make sure that all the names listed in the email have finished answering the registration form.
  3. Our care officer will reply with the availabilty of your schedule, statement of account & further instructions if any.


Please complete the following registration form to avoid delay.
The data, illegibility & integrity of results will be your responsibility, any correction of incorrect information submitted will not be accommodated, you may submit another application instead.
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