Health Declaration Form
Please fill-up this form as required by the Philippine Government that will require you to declare any illness and provide information that will aid in contract tracing, should the need arise. Be sure that the information you give is accurate and complete. All the information submitted shall be encrypted, and strictly used only in compliance to Philippine law, guidelines, and ordinances, in relation to business operation in light of COVID-19 response.
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Full Name *
Nationality *
Sex *
Age *
Contact Number *
Email Address *
Residential Address *
Foreign countries you have worked, visited, transited in the past 14 days *
Enter 'None' if not applicable. Please separate countries with a comma ( , )
Cities in the Philippines you have worked, lived or transited in the past 14 days *
Enter 'None' if not applicable. Please separate countries with a comma ( , )
Have you been sick in the past 30 days? *
In the last 14 days, did you have any of the following: fever, colds, cough, sore throat, loss of smell and taste, muscle pain, headache or difficulty in breathing? *
In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19? *
In the last 14 days, have you been in close contact with farm animals or exposed to wild animals? *
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By submitting this form, I declare that the information I have given is true, correct and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with law.

I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to The Makeover Lounge's compliance to the Republic of the Philippines COVID-19 business operations requirements and in accordance with the Data Privacy Act.
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