Health Condition Declaration Form

Pursuant to REPUBLIC ACT No. 1223 "Mandatory Reporting of Noticeable Diseases and Health Events of Public Health Concern Act", patients are required to provide truthful information about your health condition and possible exposure.

Dear Skin 101 Patient,

Kindly help us ensure your safety, as well as that of the medical staff in the clinic during and after your consult / treatment in our clinic.

We thank you for cooperation in this matter.

First Name

Email Address

Address

Last Name

Mobile Number

Are you an existing patient?

Temperature

Branch

Are you currently experiencing fever, sore throat, cough, cold, shortness of breath, difficulty breathing, headaches, low energy level, muscle pain, or new onset rashes? *

Yes

If you answered yes, kindly input the symptom/s you are experiencing?

If yes, did you consult with any medical doctor for the above mentioned symptoms?

Yes

In the last 14 days, have you worked or stayed in the same close environment with a confirmed COVID-19 case? *

Yes

In the last 14 days, have you been in close contact with a person suspected / probable case of COVID-19? *

Yes

In the last 14 days, have you traveled outside of NCR? *

Yes

If you answered yes, list down all the cities that you've been to.

If you answered yes, Did you have contract or exposure to someone who travelled in areas with local transmissions?

Yes

Vaccination Status: *

Fully Vaccinated

First dose done

Unvaccinated

Would like to receive updates regarding exclusive Skin101 discounts and promos? *

Yes

Declaration and Data Privacy and Consent

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 law. I voluntarily and freely consent to the collection and sharing of the above personal information in related to RCOC COVID-19 internal protocols and for the purpose of affecting control of the COVID-19 infection as required by RA 11469, Bayanihan to Heal as One Act. *

I agree to the terms & conditions

Your Signature

I agree to the terms & conditions

Thanks for submitting!

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