VRP Online Screening Form

ONLINE SCREENING FORM
At Victor R. Potenciano Medical Center (VRP), your health & well-being is important to us.
This Online Screening Tool will help us assist you in your upcoming health check visit at VRP. Please fill it out within 24 hours before your scheduled appointment and show a print out or screenshot of the post screening instructions together with a valid ID when you go for your visit.

YOU ARE REQUIRED TO PROVIDE TRUTHFUL INFORMATION ABOUT YOUR HEALTH CONDITION AND POSSIBLE EXPOSURE.
REPUBLIC ACT No. 11332 or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act requires the full cooperation of all persons to the mandate of the law. It is essential that you PROVIDE TRUTHFUL INFORMATION about your health condition and possible exposure.
In compliance with the Data Privacy Act of 2012, VRP Medical Center ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

ONLINE SCREENING
In compliance with the Data Privacy Act of 2012, VRP Medical Center ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.
Full Name*
First NameLast Name
Date
MonthDayYear
Chief Complaint*

ONLINE SCREENING
In compliance with the Data Privacy Act of 2012, VRP Medical Center ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.
TRAVEL AND EXPOSURE HISTORY
1.) Have you or any member of your household or close contacts traveled within or outside the country in the past two (2) weeks?*
YesNo
Location:*
From:*
MonthDayYear
Date
To:*
MonthDayYear
Date
2.) Were you exposed or living in the same household or staying in the same closed environment (workplace) with a probable/ confirmed case of COVID-19?*
YesNo

ONLINE SCREENING
In compliance with the Data Privacy Act of 2012, VRP Medical Center ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.
DEMOGRAPHICS
NOTE: Please write your information as it is written in your ID you will bring with your form as validation (e.g. Name and Birthdate)
Full Name*
First NameLast Name
Date of Birth:*
DayMonthYear
Date
AGE:
SEX:*
Contact Number:*
Area CodePhone Number
Email
example@example.com

ONLINE SCREENING
PATIENT'S/VISITOR'S CONSENT and/or DESIGNATED REPRESENTATIVE'S ASSENT
By signing this form, I confirm that: I have been informed that VRP Medical Center is undertaking these measures for the protection of everyone's . I understand that data about COVID-19 is constantly changing and despite the diligent efforts of VRP Medical Center to minimize transmission, there is still a risk of acquiring the infection. All information I have provided are TRUE and CORRECT and I am aware that any untruthful statements I make may have serious consequences on public health and safety for which I may be held liable under the law. For any of your questions and concerns, please call 8464-9999 / 5310-1818. For HMO members , you may also email us at hmoconcierge@vrp.com.ph.
Please choose:*
PatientCompanion / VisitorDesignated Representative
Signature*
Clear

ONLINE SCREENING