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.
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.