HEALTH DECLARATION FORM ONLINE

HEALTH DECLARATION FORM

(Please complete this form legibly)

Personal Information

Email *

Contact No. *

Last Name *

First Name *

Middle Initial

Address *

City *

Province/State *

Country *

Zipcode *

Nationality *

Age *

Sex *

Valid Government ID *

ID No. *

Travel History Information

Have you been travelling from other countries in the last 14 days? * YES NO

If YES, please check the name of the countries visited:

China

Hongkong

Macau

Japan

Thailand

Singapore

South Korea

Australia

USA

Germany

Taiwan

Malaysia

Vietnam

France

Others

Place comma seperator for multiple places:

Have you been travelling domestically in the Philippines? * YES NO

If YES, please check the name of the places visited:

Cebu City

Quezon City

City of Manila

City of Parañaque

City of Makati

Others

Place comma seperator for multiple places:

How many days are you staying in Bohol? *

Where will you stay in Bohol? * (Please write complete address or name of hotel in Bohol)

Daily Health Checklist

Current Temperature *

Please check if you have this symptoms *

Fever

Cough

Colds

Sore Throat

Privacy Policy

Your personal information will be kept strictly confidential and will not be sold, reused, rented, loaned or otherwise disclosed. Any information you give us will be treated with the utmost care and will not be used in ways that you have not consented to, unless you have used our websites in an unlawful manner.