Health Checklist Form

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SM City Main

Email *

Full Name *

Temperature *

Gender

Female

Male

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Age *

Residence *

Contact Number *

Are you experiencing the following: *

Body pains

Headache

Fever

Sneezing/ Runny or Stuffy Nose

Shortness of breath

NONE OF THE ABOVE

Other:

Required

Have you recently been in contact with anyone who has testedpositive for COVID-19? *

Yes

By submitting this form, you allow David's Salon SM City Main branch to collect and process the data indicated herein for the purpose of effecting control of the Covid-19 infection.

Your personal information is protected by RA 10173, Data Privacy Act of 2012, and required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

A copy of your responses will be emailed to the address you provided.

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