Health Declaration Form and Waiver
The health and well being of our patients and staff is our primary concern. Due to the current COVID-19 pandemic, we request all patients (both old and new) as well as their companion/s to fill out this questionnaire prior to their appointment. Each person must fill out a separate health questionnaire.
Patients must fill out this form regardless on when you last visited our clinic as circumstances may have changed from the last visit.
This form will enable us to ascertain whether we can tend to your immediate needs or defer your treatment so as not to risk endangering others in the clinic. Rest assured that information given in this form remains strictly confidential and protected by RA 10173 Data Privacy Act of 2012.
As required by RA 11469 Bayanihan To Heal As One Act, truthful information must be provided for the purpose of effecting control of COVID-19 infection. Please be reminded that non-cooperation of persons who should report notifiable diseases, such as COVID-19, is prohibited by law under RA 11332 Surveillance and Response to Notifiable Diseases, Epidemics, etc.
Thank you for your understanding and cooperation.
Patient's Name (First Name and Last Name)
Name of person who completed this form (if form was completed by someone other than the patient)
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