The Pain Relief Authority in the Philippines

Health Declaration Form

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

    Address

    Have you travelled abroad recently? *
    YesNo

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

    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):

    Temperature: