YOUR SAFETY IS OUR PRIORITY.
Please fill up the information on this form with honesty and full transparency as a requirement in booking your appointment; this will help us give you the safest treatment possible as well as to fight the spread of the coronavirus.
We appreciate your cooperation and understanding. Thank you.

First name
Middle name
Last name

Birthday (day)
(Month)
(Year)
Age
Contact No

Email
Patient Category

Address
City
HMO Card
Company
Card No
Is there anything else we should know before treating you? *

Are you currently experiencing an EMERGENCY? If yes, please state your condition.*
Select Branch
Appointment Details
Time

In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID-19? *
In the past 14 days, have you or any member of your household has had any contact with any COVID-19 patient? *

Do you have a fever or above normal temperature? *
Do you have a dry cough? *

Do you have a runny nose? *
Do you have a sore throat? *

Have you recently lost or had a reduction in your sense of smell? *
Have you experienced shortness of breathe or had trouble breathing? *

Are you currently undergoing any other medical treatment? *

I hereby certify, by attaching my full name digitally, that the information submitted in this application is true and correct to the best of my knowledge.