📋 Patient Intake & Document Submission

Please complete all required fields and upload the necessary documents below.

👤

① Patient's Name

Please provide the patient's last name and first name

Last Name*

Please enter the patient's last name.

First Name*

Please enter the patient's first name.

Company or Group Affiliation (optional)

📝

② Patient Consent Form

Read and agree to the terms below

💊

③ Prescription / UPSC

Upload your prescription or enter your security code

📤 Upload Prescription

🔑 Enter UPSC Code

🩺

Upload Prescription Document

PDF, JPG, PNG – issued by a licensed physician

📄

④ Authorization Form Optional

Required only if a representative will receive the delivery

Authorization Letter or Digital Authorization

✍️

Upload Authorization Letter

PDF, JPG, PNG, DOCX

Valid ID – Patient (if auth is provided)

🪪

Patient's ID

Any government ID

Valid ID – Representative (if auth is provided)

🪪

Representative's ID

Any government ID

🪪

⑤ Valid Identification (Member)

PhilHealth ID or any government-issued ID

Type of ID Submitted*

Please select your ID type.

Upload Valid ID*

📸

Upload Valid ID

Clear photo or scan – JPG, PNG, PDF

Please upload a valid ID.

📦

⑥ Delivery Address

Where should we deliver the medicine?

Contact Number*

Please enter a valid contact number.

Street / House No. / Building*

Please enter your street address.

City / Municipality*

Please enter your city or municipality.

ZIP Code*

Please enter your ZIP code.

Region*

Please select your region.

Nearest Landmark (optional)

Additional Delivery Notes (optional)

🔒 Your documents are encrypted and handled in compliance with the Data Privacy Act of 2012.
Files are securely stored and accessible only to authorized TrueMed staff.

✅

Submission Received!

Thank you. Your documents have been submitted successfully.
A TrueMed representative will review your submission and contact you within 1–2 business days.

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