Online Application
Thank you for choosing to apply for your very own RxPinoy Wish card. Kindly Complete the form below.
Name of Principal
Last Name
First Name
Middle Name


Home Address
Contact me here
Building/Floor
House No./Street
Baranggay/Village
Town/City
Phone(s), Landline(s)
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Office Address
Contact me here
COMPANY/Building/Floor
No./Street
Baranggay/Village/District
Town/City/COUNTRY
Phone(s), Landline(s)
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Personal & Contact Details
Sex
Civil Status
Mobile Phone
Primary Email
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Confirmation
I affirm that above given information is true, correct and updated. I hereby authorize RxPinoy WiSH to verify such information for whatever cause it may consider appropriate. I confirm that I have read, understood and agreed to the terms and conditions governing the issuance and use of the RxPinoy WiSH card as evidenced by my signature at right.
In-Case-of-Emergency (ICE) Alert Information
This optional function allows your critical health data to be retrievable via SMS special access numbers using the mobile number of the Principal.

Statement of Consent for the Disclosure of Personal Medical Data
I hereunto affix my signature at right to signify that I have freely given my unambiguous consent for the collection of the personal data I have disclosed above and agree to the data processing /storage/hosting of the same by RxPinoy WiSH. That the above personal medical information shall be used solely for my medical benefit for the In-Case-of-Emergency (ICE) data feature of RxPinoy WiSH. RxPinoy WiSH shall ensure at all times the protection of the above personal medical data with regard to privacy, confidentiality, content control, and, under appropriate circumstances, anonymity.