Health Checklist Form
David's Salon SM City Dasmarinas
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Temperature *
Gender *
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. *
Have you had any contact with anyone who has fever, cough, colds, and sore throat in the past 2 weeks? *
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 City Dasmarinas 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.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy