Rapid Health Assessment Questionnaire: MyHealth Venice
In line with compliance to the IATF, DOLE, DTI, and DOH, kindly fill-out this Health Declaration Form.
This must be filled out by the patient which requires MyHealth's services.
We encourage to provide complete and accurate information. All information submitted will be handled confidentially and will be used for contact tracing purposes and other reposes required in the light of COVID-19 response.
As mandated by the IATF, all information will be deleted 30 days after the date of engagement.
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Email *
Personal Information
Collected Information shall be kept confidential and processed or handled in accordance with the provisions of R.A. 10173 or the Data Privacy Act of 2012, its Implementing Rules and Regulations, as well as all directives issued by the National Privacy Commission (NPC).
Last Name *
First Name *
Middle Name
Employee Number
For MyHealth Employees only.
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Contact Number *
Note: Please provide an active contact number where we can reach you when needed. Rest assured that this will be kept confidential.
Complete Address *
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