Register Student — SEHS Clinic Portal

Student Patient Information Sheet

Fill in the sections below to register a new student and generate their clinic QR code.

Basic identity and enrollment details.

Last Name *

First Name *

Middle Name

Suffix

e.g. Jr., Sr., III

Learner Reference Number (LRN) *

12-digit number issued by DepEd.

Sex *

Date of Birth *

Age

Auto-filled from date of birth.

Grade Level *

Section *

Student Contact Number *

Home Address *

House no., street, barangay, city.

The primary guardian is also used as the emergency contact.

Primary Guardian Name *

The adult responsible for the student.

Relationship to Student

Guardian Contact Number *

Used as the emergency contact number.

The primary guardian above will be recorded as the student's emergency contact.

Conditions the clinic should know about. Write 'None' if applicable.

Blood Type *

Height (cm)

Weight (kg)

Known Allergies

Food, medicine, environmental.

Chronic Illness / Conditions

Asthma, diabetes, hypertension, etc.

Current Medications

Previous Hospitalizations / Surgeries

Include approximate year, if any.

Authorization for the school clinic to provide care.

I authorize the SEHS clinic staff to provide routine medical treatment and first aid to the student as needed.

In case of emergency, I authorize the clinic to arrange urgent medical care or transport to the nearest hospital if I cannot be reached.

Parent / Guardian Name (e-Signature) *

Date of Consent *

Required fields are marked with *.