COVID-19 RT-PCR TEST QUESTIONNAIRE

Please fill out the following form as required by the Mandatory Reporting of Notifiable Diseases & Public Health Concerns Act of 2019, their Implementing Rules & Regulations, and other pertinent guidelines of the Philippine Department of Health.

First Name

Middle Initial

Last Name

Age

Date of Birth

Citizenship

Occupation

Email Address

Mobile #

# of Persons in Household

Please upload your government issued valid ID

Upload File

Emergency Contact

First Name

Middle Initial

Relationship

Last Name

Age

Email Address

Mobile #

Current Residence Address

Unit # / House # / Lot # / Blk. / Building / Street

Barangay

City / Municipality

Province & Region

Postal / Zip code

Permanent Address

Same as above

Unit # / House # / Lot # / Blk. / Building / Street

Barangay

City / Municipality

Province & Region

Postal / Zip code

Office Details

Same as above

Not Applicable

Unit # / Lot # / Blk. / Building / Street

Barangay

City / Municipality

Province & Region

Postal / Zip code

Phone

Company Email Address

Company Mobile #

Vaccination Information

Unvaccinated

Other

LGU of Vaccination

Date of 1st Dose

Date of 2nd Dose

Date of 3rd Dose

Vaccination Verification Code

Upload Official Vaccination Card

Upload File

Other Health Information

Have you ever been infected with COVID-19?

Yes

Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

If you answered "Other/s", please specify:

Date of LMP

Were you ever diagnosed with any severe respiratory illness?

Yes

Requested Testing Date

Do you have any concerns, questions or comments?

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.

Today's Date

COVID-19 RT-PCR TEST QUESTIONNAIRE

Emergency Contact

Current Residence Address

Permanent Address

Office Details

Vaccination Information

Other Health Information

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