[HICEC] Online Screening Tool 3

ONLINE SCREENING TOOL
At The Medical City (TMC), your health and well-being is important to us.

This Online Screening Tool will help us assist you in your upcoming health check visit at TMC. Please fill-out this form 24 hours before your scheduled appointment and show a printed copy or screenshot of your screening result instructions together with a valid ID when you go for your visit.

Republic Act No. 11332 or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Concern Act requires the full cooperation of all persons to the mandate of the law. It is essential that you PROVIDE TRUTHFUL INFORMATION about your health condition and possible exposure.

In compliance to IATF Resolution No. 150 s.2021 issued on 25 Nov 2021, we would like to remind patients and companions to WEAR MASK when inside the hospital premises.
In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

VISIT INFORMATION
Please choose one:*

PatientCompanion (e.g., patient's caregiver, relative)Visitor
Location of Visit*

Department / Service ClinicNursing Unit / Patient RoomDoctor's ClinicOthers
Department / Service Clinic
In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

TRAVEL AND EXPOSURE HISTORY
Have you had ANY close contact (been within 1 meter of each other for more than 15 minutes) with someone who are known to have COVID-19?*

YesNo
In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

DEMOGRAPHICS

NOTE: Please write your basic information as indicated on your valid ID.
Complete Name*

First NameMiddle NameLast NameSuffix
Birthdate*

MonthDayYear
Date
Sex*

MaleFemale
Current Date

MonthDayYear
Date
Validity Date

MonthDayYear
Date
Age
Contact Number*
Landline No. / Mobile No.
Email Address
example@example.com
In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

INFORMED CONSENT

By accomplishing this form, I confirm that:

I have been informed that The Medical City is undertaking these measures to ensure that the well-being and protection of everyone, myself included, is prioritized.

I understand that information about COVID-19 is constantly changing and despite the diligent efforts of The Medical City to minimize transmission, there is still a risk of acquiring the infection.

And, that the information I have provided are TRUE and CORRECT and I am aware that any untruthful statements I make may have serious consequences on public health and safety for which I may be held liable under the law.

Risk Score
Risk Status
In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.
Should be Empty:

In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.

In compliance with the Data Privacy Act of 2012, The Medical City ensures that the information you provide will be kept strictly confidential and will only be processed, disclosed, or shared upon your consent, or as required by law.