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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.

Testing Category/Subgroup (Check all that apply)
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Emergency Contact

Current Residence Address

Permanent Address

Office Details

Vaccination Information

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Other Health Information

Have you ever been infected with COVID-19?
Are you currently suffering from a medical condition, illness, or injury?
Do you have any comorbidities? (Please check all that apply)
Were you ever diagnosed with any severe respiratory illness?
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