EmailMe Form - Care+Center Teleconsult Registration Form

Care+Center Teleconsult service operates daily, even on Holidays, unless otherwise advised.

Please see our schedule below:

Mondays to Sundays - 8 AM to 7 PM

IMPORTANT : This service applies to patients with NON-EMERGENCY CONCERNS.

If you have any concerns or inquiries, you may contact our numbers below:

09669550092

09954324800

09989680462

09985395821

Will you be using an HMO card? *

Yes

No. I will be paying for the service

Select HMO provider: *

Your consultation needs

How can we help you? *

Explain the reason for consultation, i.e. illness, pain, symptoms, etc.

If available, upload laboratory test results, x-ray images, or pictures. You may send your files via email to teleconsult@keralty.com.ph if they fail to get uploaded.

Accepted file types include pdf, doc, docx, jpg, jpeg, png, gif. The limit size per file is 3 MB.

Select from the available specialties for your HMO: *

Select from the available specialties: *

Enter the name of your doctor (if applicable):

Select preferred schedule: *

MM / DD / YYYY HH : MM AM/PM

NOTE : Requests for medical certificates, medical clearances, and nutritional plans entail additional charges.

Personal Information

Name of Patient *

First Middle Last

Gender *

Male

Female

Nationality *

Birth Date *

MM / DD / YYYY

Age *

Contact Number *

Email Address *

Address *

Street Address City State / Province / Region Postal / Zip Code

Upload a photo of any valid Government ID. *

Accepted file types include jpg, jpeg, png. The limit size per file is 3 MB.

HMO INFORMATION

HMO Card/Account Number *

Company Name of Principal HMO Card Holder:

Upload a photo of the front and back portion of your valid HMO Card: *

Accepted file types include jpg, jpeg, png. The limit size per file is 3 MB.

If you already have an electronic approval, please upload a copy in PDF form.

Accepted file types include pdf. The limit size per file is 3 MB.

Click here to read the Terms and Conditions and Data Privacy Statement

Terms and Conditions and Data Privacy Statement

About Keralty Teleconsult service and its terms and conditions

The Keralty Teleconsult will be given by licensed physicians. It is not a substitute to a face-to-face consultation.
• After requesting for the service, and paying in case of out-of-pocket patients, our staff will be contacting you to finalize your appointment schedule.

• A link will be emailed to you for the video conference. Please click on the link to join the conference at the appointed time of consultation.

Data Privacy Consent

The request of personal information on this online form is done with the sole purpose of processing and managing your request. In accomplishing the information requested, you agree that Metro Sanitas Corporation and/or its subsidiaries or shareholder companies will process these Personal Information relating to you. Such processing of Personal Information may include its collection, recording, updating, modification, retrieval, use, and retention. You are also consenting to:

1. Making your Personal Information available to the relevant employees of Metro Sanitas Corporation, its subsidiaries or shareholder companies, and any service provider that may be involved in the process and management of this event;

2. The processing of your Personal Information for generating statistical data relevant to this specific activity;

3. The retention by Metro Sanitas Corporation of your Personal Information for the period necessary for the purpose of this request. We will dispose of your Personal Information upon the lapse of the Personal Data Retention Period in accordance with applicable laws and regulations. You are entitled to certain rights in relation to the Personal Information that may be collected from you, including the right to access, correction, and to object to the processing of the same. Your information will be held securely and will not be made available to third parties others that the ones require to provide this service without your expressed consent.

For The Terms and Conditions, you may review it through this page: https://keralty.com.ph/keralty-teleconsult-terms-and-conditions/

By ticking the checkbox below, you hereby certify that you understand the foregoing and that you are giving your consent to the processing of your Personal Information and Sensitive Personal Information under the terms and conditions provided above, and to contact you in case it is required to process your request.

Data Privacy Consent and Terms and Conditions: *

I understand and agree with the above data privacy statement and Keralty Teleconsult terms and conditions.

Would you like to receive emails on promotions and offers from Keralty?

Yes, I'm interested.

How did you know about Care+Center? (You may select more than one)

Payment Instructions

You will be redirected to the payment site upon submission of this form. Please input the name of the patient on the space for customer name. A refund fee of PhP 60 will be charged for cancellations unless the fault is on us. *** NOTE FOR PWD ID HOLDERS, please disregard the payment site. We will contact you and a courtesy discount will be given before you make a payment.