Application

Designate a health care proxy

Both people must be at least 21 years old and residents of Iloilo City, and must not be related to each other by blood or affinity.

Application type This is a reciprocal couple application

Leave this checked if both people are designating each other. Uncheck it if one person (Applicant A) is designating the other (Applicant B) as their agent, without a reverse designation. Either way, both people's details are required below.

Applicant A — the principal First name Last name Birth date Mobile number Applicant A is a resident of Iloilo City

Applicant B — the designated agent First name Last name Birth date Mobile number Applicant B is a resident of Iloilo City

Attestations The applicants are not related to each other by blood or affinity

Applicants must be at least 21 years old and residents of Iloilo City. A proxy is a designation between unrelated adults.

Privacy Notice

Please read this notice. It explains how your personal data is used.

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Both applicants have read and understood the Privacy Notice above and consent to the processing of their personal data for the Right to Care program.