Health Declaration

Health Declaration Form

In compliance to the government’s directives to mitigate the spread of Covid-19 and likewise to assure your health, we would request for your cooperation in taking precautionary measures to avoid its spread. Part of this activity is by accomplishing the questionnaire below which is aligned with the Statement of Declaration released by the Department of Health of the Philippines.

We would appreciate if you could answer candidly the following questions. Once completed, kindly forward/submit to our official store email oddscafeandnailspa@gmail.com prior to your entry.

In providing below information details, you agree to give consent to our collection, use, processing, transfer, and/or disclosure of your personal data in accordance with all applicable laws for purposes of monitoring, evaluating, and responding to the novel coronavirus (COVID-19) outbreak.

1. Do you have fever, a dry cough, breathing difficulties, severe muscle aches, continuous chest pains or chills and shivering?

Response: *

Yes No

2. Are any of your family members, close relatives or friends have fever, cough, or having difficulty to breathe?

Response: *

Yes No

3. Have you had any contact with a Covid-19 related pneumonia patient in the past 14 days?

Response: *

Yes No

4. Have you visited other countries in the last fourteen (14) days? If your answer is yes, please state below the country of origin.

Response: *

Yes No

Country of origin *

* Indicates required field

Name *

First

Last

Contact number *

Email *

Submit

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