Doctor with Files

Online Health

Declaration Form

Control Number

Have you been sick in the past 30 days?
Please fill-up this form as required by the Philippine Government that will require you to declare any illness and provide information that will aid in contract tracing, should the need arise. Be sure that the information you give is accurate and complete. All the information submitted shall be encrypted, and strictly used only in compliance with Philippine law, guidelines, and ordinances, in relation to business operation in light of COVID-19 response.
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Do you currently have symptoms of, or have you been diagnosed with pneumonia or coronavirus disease? (COVID-19)
In the last 14 days, did you have any of the following: (Leave everything empty if you have no signs)
In the past 14 days, have you been in contact with someone who is infected with coronavirus?

The information I have given is true, correct, and complete.  I understand that failure to answer any question or give false answers can be penalized in accordance with the law.

Please be advised that the above information shall only be used in relation to the COVID-19 internal protocols in accordance with the Data Privacy Act. 

Please complete the form to proceed.

 
Please, Fill up the empty fields!
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Formats: xxx-xxx-xxxx, xxx.xxx.xxxx, xxx xxx xxxx
Example: 949-123-1234 or 9491231234 (will work as well)
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