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COVID Declaration Form
Please answer the Health check list for the purpose of achieving control of the COVID-19 infection. Take notice that the following should be provided with truthful information as mandated by the RA 11469, BAYANIHAN to Heal as One Act.
Nicatto will collect personal data to help prevent or minimize any potential risk of COVID-19 spreading. These data will be used to assess the suitability of any visits planned and/or used for contact purposes in the case of confirmed or suspected cases.
1. Are your experiencing the following:
A. Flu- like symptoms
B. Cough
C. Sore Throat
D. Body pain
E. Headache
F. Difficulty in Breathing
G. FEVER
IF YES: HOW MANY DAYS?
2. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
3. Have you been in close contact with anyone who has fever, sore throat, body pains, head ache and flu like symptoms in the last 14 days?
4. Have you traveled outside the Philippines within the last 14 days to one of the countries declared to have Corona Virus?
5. Have you been in close contact with anyone who has traveled within the last 14 days to one of the countries declared to have Corona Virus ?
I understand that, in case of a COVID-19 suspect or confirmed case, Nicatto is required to share my information to the Department of Health, its local counterparts and my employer in compliance with the Philippine laws on disease surveillance and other applicable rules and issuances.
By submitting this form, I consent to the collection, use, storage and retention of my personal data for monitoring and reporting of COVID-19 cases as required under the laws.
Please complete the form.
Clinic Locations:
1405 The Jollibee center Building San Miguel Ave. Ortigas Center Pasig City,
Cluster 3 walkway extension, CENTRIS MALL, EDSA corner Quezon Ave. Quezon City
S01-S02 Second Floor SOUTHGATE Mall, Chino Roces ave. cor. EDSA, Makati City
Contact:
Telephone:+63 739-1991 Mobile:+63 917-517-1991 | +63 919-006-9437
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