Health Declaration Form

Health Declaration Form

Please fill-up this form as required by the Philippine Government that will require you to declare any illness and provide information that will aid in contract tracing, should the need arise. Be sure that the information you give is accurate and complete. All the information submitted shall be encrypted, and strictly used only in compliance to Philippine law, guidelines, and ordinances, in relation to business operation in light of COVID-19 response.
Name*

First NameMiddle NameLast Name
Nationality*
Sex*

MaleFemale
Age*
Contact Number*
Landline or Mobile Number
Email Address*
example@example.com
Present Address*
Foreign countries you have worked, visited, transited in the past 14 days*
Enter 'None' if not applicable. Please separate countries with a comma ( , )
Cities in the Philippines you have worked, lived or transited in the past 14 days*
Enter 'None' if not applicable. Please separate countries with a comma ( , )
Have you been sick in the past 30 days?*

YesNo
If Yes, please describe your condition and what hospital did you visit, if any?*
In the last 14 days, did you have any of the following: fever, colds, cough, sore throat, loss of smell and taste, muscle pain, headache or difficulty in breathing?*

YesNo
If Yes, please specify these

FeverColdsCoughSore ThroatLoss of Smell and TasteMuscle PainHeadacheDifficulty in Breathing
In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19?*

YesNo
If Yes, please describe the circumstances*
In the last 14 days, have you been in close contact withfarm animals or exposed to wild animals?*

YesNo
If Yes, please describe the circumstances*
Declaration and Data Privacy Consent Form:

By signing this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with law.

I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to Handuraw Pizza's compliance to Republic of the Philippines COVID-19 business operation requirements and in accordance with the Data Privacy Act. For any concerns, you may contact admin@handurawpizza.com.
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Signature*

Clear
We only allow four (4) people at a time.
Should be Empty:

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