Health Checklist Form
David's Salon SM Cabanatuan
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Email *
Temperature *
Full Name *
Gender
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Age *
Residence *
Contact Number *
Are you experiencing : body pains, headache, fever for the past few days, fatigue, cough, sneezing, diarrhea, runny or stuffy nose, shortness of breath, ? If yes, please specify. *
Required
Have you recently been in contact with anyone who has tested positive for COVID-19? *
By submitting this form, you allow David's Salon SM Cabanatuan branch to collect and process the data indicated herein for the purpose of effecting control of the Covid-19 infection.

Your personal information is protected by RA 10173, Data Privacy Act of 2012, and required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.
A copy of your responses will be emailed to the address you provided.
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