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Health Declaration

Please fill out the following form
in order to participate in our activity.

First Name

Last Name

Complete Address

Email

Contact Number

My body temperature is lower than 37.5°C *

No

Yes

I am not experiencing COVID-19 symptoms: cough, sore throat, fever *

No

Yes

I have not been in close contact with a COVID-19 patient for the past 14 days. *

No

Yes

Date

I declare that the info I’ve provided is accurate & complete

ADDRESS

123 Maharlika Highway, Ibabang Dupay, Lucena City, Quezon Province

Tel: 123-456-7890

OPENING HOURS

Monday - Friday: 8:00am – 5:00pm Saturday: 8:00am – 4:00pm

SUBSCRIBE TO JOIN OUR MAILING LIST

Thanks for submitting!

© 2022 by E-ISKED MO!

FOR EDUCATIONAL PURPOSES ONLY

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