Member Registration

Access Details

User Name/User Email Id *

Why?

Your Email Address

	Your Emal ID will be the user name to login to your Philippine Health Card account in the future.
	We take your Email security seriously.
	Your privacy is our priority. We assure you that we will not release your information to anyone.

Password *

Why?

Your Password

Your password will be the login to your Philippine Health Card account in the future.

Note: Password length should be minimum of six characters.

Confirm Password *

Type of Card *

Individual Card Membership Fee $15Family Card Membership Fee $45

Security Question *

Answer

Personal Details

First Name *

Middle Name

Last Name *

Date of Birth*

MM/DD/YYYY

Sex*

MaleFemale

Address 1 *

Address 2

Country *

Province *

City *

Zip

Phone Number

Mobile Number

Email Id

How did you hear about us?

	Nominate me as Beneficiary

	Primary Beneficiary Card Holder Information

Additional Beneficiary Information

	Registration Complete

Processing your information