TrueMed – PhilHealth YAKAP GAMOT Availment Form

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1 Patient Information

Last Name*

Last name is required.

First Name*

First name is required.

Middle Name*

Middle name is required.

Birthday*

Birthday is required.

Email (optional)

Please enter a valid email address.

Walk In / Company / Group*

Please select an option.

2 Patient Consent

3 Prescription

Prescription Photo*

🩺

Scan your prescription

Issued by a licensed physician

Prescription photo is required.

Clinic*

Clinic name is required.

UPSC Code*

UPSC code is required.

4 Valid Identification (Member)

ID Type*

Select an ID type.

Upload Valid ID*

📸

Tap to choose file

JPG, PNG or PDF · both sides if applicable

A valid ID is required.

5 Patient Signature

Sign below*

Draw your signature here

Signature is required.

6 Delivery Address

Contact Number*

Enter a valid contact number.

Street Address*

Street address is required.

City*

City is required.

ZIP Code*

ZIP code is required.

Region

Landmark

Delivery Notes

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Documents Submitted

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A TrueMed representative will reach out within 1–2 business days.

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