You may fill out this Health Declaration Form before coming over for your appointment. Please select the clinic, as well as the time and date for your visit.

A copy will be sent to your email — you may print it and bring it with you on your visit.

Thank you!

Declaration and Data Privacy Consent

By filling out this form, I confirm that the information I have given is true, correct and complete. I understand that failure to answer any question or giving false answer can be penalized in accordance with the law. I voluntarily and freely consent to the collection and sharing the following personal information in relation to COVID-19 internal protocols affecting control of the COVID-19 infection as required by RA. 11469, Bayanihan to Heal as One Act.

    All fields required:

    Your Name

    Your Email

    Contact Number


    Have you travelled abroad recently? *

    Have you been in contact with people infected, suspected or diagnosed with COVID-19?

    Please state whether you've experienced/are experiencing the following:
    Fever YesNo
    Cough YesNo
    Shortness of Breath YesNo
    Persistent Chest Pain YesNo

    Clinic Location:

    Appointment date (mm/dd/yyyy):

    Appointment time (hh:mm AM/PM):