On-Site COVID-19 Testing Form | 1HealthPASS™️

I hereby declare that any and all data and / or information I have provided and submitted are true and correct information to the best of my knowledge. In compliance with the Data Privacy Act of 2012, Mandatory Reporting of Notifiable Diseases and Public Health Concerns Act of 2019, their Implementing Rules and Regulations, and other pertinent guidelines of the Philippine Department of Health, I am hereby granting my consent to the collection, processing, and disposal of my personal and sensitive information for the purpose of availing the SARS-CoV-2 diagnostic testing procedure. I hereby further agree for my information and data to be submitted, deposited & stored as well as to be subject to and abide by any and all terms & conditions of HelpMed®️ and, to any and all amendments thereto. If I do not agree to such, I will conclude and express such by NOT clicking on the box provided, wherein I hereby duly acknowledge that I will not continue with my application.

N/A - Regular / Required Testing

A: Individuals with severe/critical symptoms and relevant history of travel and/or contact

B: Individuals with mild symptoms and relevant history of travel and/or contact

C: Individuals with mild symptoms

D: Individuals with no symptoms but with relevant history of travel and/or contact or high risk of exposure.

D1: Contact-traced individuals

D2: Healthcare workers

D3: Returning Overseas Filipino Workers

D4: Filipino citizens in a specific locality within the Philippines who have expressed intention to return to their place of residence/home origin (Locally Stranded Individuals) may be tested subject to the existing protocols of the IATF.

E: Frontliners indirectly involved in health care provision in the response against COVID-19.

E1: Those with high or direct exposure to COVID-19 regardless of location may be tested up to once a week.

E2: Those who do not have high or direct exposure to COVID-19 but who live or work in Special Concern Areas may be tested up to every two to four weeks.

F: Other vulnerable patients and those living in confined spaces.

G. Residents, occupants or workers in a localized area with an active COVID-19 cluster

H: Frontliners in Tourist Zones

H1: All workers and employees in the hospitality and tourism sectors.

I: All workers and employees of manufacturing companies and public service providers registered in economic zones located in Special Concern Areas

J1: Frontline and Economic Priority Workers

Altered Mental Status

Anosmia ( loss of smell, w/o any identified cause )

Ageusia ( loss of taste, w/o any identified cause )

We hereby willfully and voluntarily declare that any and all information and data stated herein are true and correct to the best of our knowledge.

I agree to all terms & conditions

COVID-19 ON-SITE TESTING FORM

Emergency Contact

Current Residence Address

Permanent Address

Office Details

Vaccination Information

Other Health Information

To be filled-out by Healthcare Administrator

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