HEALTH DECLARATION FORM
In accordance with RA11332 “Mandatory Reporting of Notifiable Disease and Health Events of Public Health Concern Act” all guests are required to answer this HEALTH DECLARATION FORM truthfully and accurately.
*If any symptoms or conditions stated below are present, we advise to reschedule your visit.
* Required
Email address
*
Your email
CONFIRMED BOOKING
*
Day Tour
Afternoon Tour
Overnight
Required
ARRIVAL
*
MM
/
DD
/
YYYY
DEPARTURE DATE
*
MM
/
DD
/
YYYY
For contact tracing, please provide the complete information below:
FULL NAME (last name, first name, middle initial): *
*
Your answer
COMPLETE ADDRESS: *
*
Your answer
CONTACT NUMBER
*
Your answer
DATE OF BIRTH
*
MM
/
DD
/
YYYY
AGE
*
Your answer
SEX: *
*
MALE
FEMALE
Required
CIVIL STATUS
*
SINGLE
MARRIED
OTHERS PLEASE SPECIFY
Required
OCCUPATION
*
Your answer
SIGNS AND SYMPTOMS
Please place a mark on your answer below:
Do you have any of the following within 14 days before your visit to Luljetta's Place Spa & Wellness today?
*
FEVER
COUGH OR COLDS
CHILLS
DIFFICULTY OF BREATHING
DIARRHEA
HEADACHE
SORE THROAT
JOINT PAINS
MUSCLE PAINS
LOSS OF TASTE AND/SMELL
NA
Required
Do you have any history of :
*
Exposure to any individuals with flu-like symptoms (including sore throat and body pains) in your household or work place?
Exposure to a confirmed case of COVID-19?
Exposure to a COVID-19 suspect/ probable case?
Travel to any areas in NCR or any areas under Enhanced Community Quarantine (ECQ) protocol aside from your home in the last 14 days?
Travel outside the Philippines in the last 14 days?
Being diagnosed with COVID-19
NA
Required
Are your currently living in an area which is still under the Enhanced Community Quarantine (ECQ) protocol? *
*
Yes
No
Required
Confirmation of Answers and Data Privacy Policy Content
Luljetta's Place Spa and Wellness, in line with Republic Act 10173 or the Data Privacy Act of 2012, is committed to protect and secure personal information obtained in the performance of its duties. These establishment collects the following personal information relevant in the advancement of protocols and precautionary measures against COVID-19 Acute Respiratory Disease. The collected personal information will be kept/stored and accessed only by authorized personnel and will not be shared with any outside parties unless the disclosure is required by, or in compliance with applicable laws and regulations. Declaration and Data Privacy Consent Form: I knowingly and voluntarily agree to the terms of this binding Declaration, and in doing so represent the truthfulness and veracity of the above answers. I understand that failure to answer any question or giving false answer can be penalized in accordance with the law. Relative thereto, I voluntarily and freely consent to the processing and collection of personal data only in relation to COVID-19 internal protocols.
*
I agree and understand
Required
FULL NAME (last name, first name, middle initial):
*
Your answer
DATE
*
MM
/
DD
/
YYYY
Send me a copy of my responses.
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