Health Declaration Form
The safety of our customers and our staff remains the top priority of the company. As the outbreak of COVID-19 continues, we remain vigilant in preventing its spread. Please answer this form truthfully.
Full Name
Last Name
First Name
Age
Sex
Male
Female
Contact Number
1. Did you visit a hospital, clinic, or any medical health facility in the past 14 days?
Yes
No
2. In the last 14 days, have you been in close contact with a suspect case, a probable case or a confirmed COVID-19 positive patient?
Yes
No
3. In the last 14 days, did you have any of the following:
Fever
Colds
Cough
Sore throat
Difficulty in breathing
None
Certification and Date Privacy Consent
I certify that the information I have provided are true and accurate. I hereby give my full consent to Fifty NineFlower Cafe to collect, record, and process information, whether personal, sensitive or privileged, pertaining to myself for the purpose of drafting and implementing internal policies related to the prevention or containment of COVID-19
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Salad & Sandwiches
59 House Sandwich
140 PHP
140
PHP
white bread, bacon, ham, egg, tomato, cucumber, lettuce, mayonnaise
Quantity
59 House Salad
180 PHP
180
PHP
lettuce, carrots, tomatoes, chicken, cucumber, cheese, croutons, mango dressing
Quantity
Tuna Melt Sandwich
130 PHP
130
PHP
tuna flakes, carrots, onion, mayonnaise
Quantity
Veggie Burger
230 PHP
230
PHP
plant-based patty, mozzarella cheese, bread, lettuce
Quantity
Pasta
Meaty Lasagna
260 PHP
260
PHP
beef, mozzarella, parmesan, bechamel sauce, fresh pasta
Quantity
Moussaka
230 PHP
230
PHP
eggplant, melted cheese, bechamel sauce
Quantity
Mushroom Ravioli
190 PHP
190
PHP
fresh pasta, mushroom, shallot, cheese, tomato
Quantity
Papardelle Chicken Pesto
290 PHP
290
PHP
chicken, pesto, cheese
Quantity
Wild Mushroom Linguine
250 PHP
250
PHP
button mushroom, shiitake mushroom, olive oil, spring onion
Quantity
Spaghetti alla Puttanesca
250 PHP
250
PHP
capers, black olives, parmesan, olive oil, garlic, parsley
Quantity
Mains
Fish & Chips
195 PHP
195
PHP
cream dori fish, lemon, egg, flour, bread crumbs, tartar sauce
Quantity
Sides
Mashed Potatoes
Rice
Pork Tonkatsu
300 PHP
300
PHP
pork chop, bread crumbs, flour, egg, tonkatsu sauce
Quantity
Sides
Mashed Potatoes
Rice
Garlic Mushroom Beef
350 PHP
350
PHP
beef cutlets, button mushroom, shiitake mushroom, garlic, butter
Quantity
Sides
Mashed Potatoes
Rice
Bacon Stuffed Chicken
220 PHP
220
PHP
chicken breast, mustard, cheddar cheese, mozzarella, bacon
Quantity
Sides
Mashed Potatoes
Rice
Crepes
Parisian Butter & Sugar
100 PHP
100
PHP
plain crepe with butter and refined sugar
Quantity
Dark Crepe
130 PHP
130
PHP
cocoa powder, cream, chocolate syrup, crushed oreos
Quantity
Banana Nutella Crepe
150 PHP
150
PHP
fresh banana, nutella, butter, chocolate syrup
Quantity
Coffee
59 Black Coffee
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Mocha
125 PHP
125
PHP
Hot / Iced
Hot
Iced
Quantity
Latte
115 PHP
115
PHP
Hot / Iced
Hot
Iced
Quantity
Caramel Macchiato
125 PHP
125
PHP
Hot / Iced
Hot
Iced
Quantity
Flat White
115 PHP
115
PHP
Hot / Iced
Hot
Iced
Quantity
Cappucino
115 PHP
115
PHP
Hot / Iced
Hot
Iced
Quantity
Cafe Con Leche
135 PHP
135
PHP
Hot / Iced
Hot
Iced
Quantity
Pour-over Coffee
115 PHP
115
PHP
Quantity
Tea
Butterfly Pea
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Chamomile
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
French Rose Bud
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Lavender
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Hibiscus Roselle
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Sweet Raspberry
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Vanilla Cocoa Black Tea
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Chamomile Apple Tea
105 PHP
105
PHP
Hot / Iced
Hot
Iced
Quantity
Other drinks
Chocolate
130 PHP
130
PHP
Hot / Iced
Hot
Iced
Quantity
Japanese Uji Latte
120 PHP
120
PHP
Matcha
Hot / Iced
Hot
Iced
Quantity
Rose Tea Latte
120 PHP
120
PHP
Hot / Iced
Hot
Iced
Quantity
Iced Tea
105 PHP
105
PHP
Quantity
Bottled Water
30 PHP
30
PHP
Quantity
Total
0.00 PHP
0.00
PHP
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