Health Declaration Form

Dear Patient Partner,

We are committed to provide safe, quality and holistic healthcare services amidst the pandemic.

This Online Screening Tool will help us assist you as we strive to give you a hassle-free and comfortable visit at The Medical City South Luzon.

Make sure to fill-out this Online Screening Form before your scheduled appointment and secure a printed or screenshot copy together with a valid ID when you go for your visit.

We will be pleased to welcome and serve you here at The Medical City South Luzon, your home in the new normal.

PERSONAL INFORMATION

Lastname

Firstname

M.I

Complete Address

Contact no.

Email address

Birthday

Age

Gender

Temperature

VISIT INFORMATION

I'm visiting as

Patient

Companion

Visitor

Location of Visit

Department / Service Clinic

Nursing Services / Patient Room

Doctors Clinic

Administrative Offices

Other

Select specific location

Please type other option here

TRAVEL AND EXPOSURE HISTORY

Have you had ANY close contact (been within 1 meter of each other for more than 15 minutes) with someone who are known to have COVID-19?

Yes

Have you or any member of your household or close contacts traveled within or outside Laguna recently?

Yes

Were you exposed or living in the same household or staying in the same closed environment (workplace) with a probable/ confirmed case of COVID-19?

Yes

Contact or exposure to someone with recent travel to an area with local transmission of COVID-19?

Yes

CONSENT

By filling up this form, I confirm that:

I have been informed that The Medical City South Luzon is undertaking these measures to ensure that the well-being and protection of everyone, myself included, is prioritized. I understand that data about COVID-19 is constantly changing and despite the diligent efforts of The Medical City South Luzon to minimize transmission, there is still a risk of acquiring the infection.

The information I have provided are TRUE and CORRECT and I am aware that any untruthful statements I make may have serious consequences on public health and safety for which I may be held liable under the law.

For any of your questions and concerns, please call (049)-303-3000.

I agree to the statement above

I agree

Online Health Declaration Form

PERSONAL INFORMATION

VISIT INFORMATION

SIGN OF SYMPTOMS

TRAVEL AND EXPOSURE HISTORY

CONSENT