Health Declaration Form
(for Check-In Guests)

Name *

First Name

Last Name

Gender *

Male

Female

Mobile Number *

63 - Philippines Country Code

Country

(###)

###

####

1. Did you visit a hospital, clinic, or any medical health facility in the past 14 days? *

Yes

No

2. In the last 14 days, have you been in close contact with a suspect case, a probable case or a confirmed COVID-19 positive patient? *

Yes

No

3. In the last 14 days, did you have any of the following: *

Kindly check all that apply.

Fever

Dry Cough

Fatigue

Aches and Pains

Runny Nose

Sore Throat

Shortness of Breath

Diarrhea

Headache

Loss of Smell and Taste

None

*

I certify that the information I have provided are true and accurate. I hereby give my full consent to Rublin Hotel Cebu to collect, record, and process information, whether personal, sensitive or privileged, pertaining to myself for the purpose of monitoring and tracking hotel guests in relation to the government implementations on COVID-19.