Health and Wellness Profile
Your health and safety is our priority. In order to provide you with the best care and treatment, kindly fill out the Health Questionnaire form accurately. AesthetiQ adheres to the Data Privacy Act and will not use your data for other purposes.
Name
*
First Name
Last Name
Suffix
Sex
*
Male
Female
Address
*
Street Address
Barangay
City/Municipality
Province
Zip Code
Age
*
Nationality
*
Mobile Number
*
-
Mobile Prefix
7 Digit Number
Do you want to join our Viber Community?
*
Yes
No
Email
*
example@example.com
Branch
*
West Ave
Robinsons Magnolia
COVID-19 SCREENING
In the last 60 (sixty) days, have you been tested for COVID-19?
*
Yes
No
If YES, for what purpose?
*
Work
Travel
Domestic
N/A
If YES, please indicate date swabbed and result (if available).
*
No
Other
Have you travelled in the last 15 days?
*
Yes
No
If YES, where: (Otherwise, write N/A)
*
Country, Province, City
Have you been evaluated as Probable or Suspected for COVID-19?
*
Yes
No
If YES, when did your quarantine start?
/
Month
/
Day
Year
Date Picker Icon
Have you been in contact or staying in the same close environment with anyone in the last 14 days who has been diagnosed with COVID-19 or is a Probable/Suspected case?
*
Yes
No
Please state whether you've experienced/are experiencing the following
*
YES
NO
Fever
1
2
Tiredness
3
4
Headache
5
6
Cough
7
8
Breathing Difficulty
9
10
Gastrointestinal Symptoms
11
12
Loss of sensation of smell
13
14
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventive measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.
*
I understand
I agree that the information provided in this form is true and correct to the best of my knowledge and understand that any dishonest answer may have serious legal and public health implications under RA 11332.
*
I agree
Consent for Treatment
I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may been elevated risk of disease transmission, including COVD-19. By clicking "I agree" in this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from AesthetiQ Wellness & Spa.
*
I agree
Signature
*
Submit
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