HEALTH DECLARATION FORM

Valid on day of consult only. Present this to the department you will visit.
You must provide TRUTHFUL information about YOUR health condition and possible exposure. Any falsification is PUNISHABLE with one to six
months IMPRISONMENT and a 20,000 to 50,000 FINE (Republic Act 11332).

Full Name: Date Accomplished:

Contact Number: Email Address:

Address:

Vaccination Status:

Fully Vaccinated (received 2 doses of COVID-19 vaccine) Partially

Vaccinated (received 1 dose of COVID-19 vaccine) Unvaccinated( did not
receive any COVID-19 vaccine)

Instruction: Please tick the appropriate response if YES or NO.

EXPOSURE WITHIN THE PAST 14 DAYS (from date of visit) YES NO

1. Did you have any international or local travel or are you residing in a place with reported increase of COVID- 19
cases within the past 14 days?

2. Did you have any direct exposure (within 2 meters and for more than 15 minutes without wearing medical
mask/N95 respirator) with a person positive for COVID-19?

3. Do you have a pending COVID-19 test result (RT-PCR or Rapid Antibody Test)?

4. Have you tested positive for COVID-19 within the past 7to14 days?

SIGNS AND SYMPTOMS (during the date of visit) YES NO

5. Did you have any of the following signs and symptoms?

Fever of more than 38°C Difficulty of breathing,

Cough Shortness of breath
Colds Influenza-like symptoms (headache, muscle and joint pains, lack
Sore throat of smell or taste)

6. Have your signs and symptoms not improved

For any further inquiries, kindly call the extension number of the unit you intend to visit.

The undersigned declares that the information contained in this Health Declaration Form is true and that I am legally liable for any falsification
contained therein.

Signature of Accomplisher

QF-IPC-103
Rev. 01
March 2022
 CONFIDENTIALITY AGREEMENT
Asian Hospital & Medical Center has a legal and ethical responsibility to safeguard the privacy of all patients and
protect information that is identified as confidential. Confidential information shall mean all information, which relates in any
way, to patient records, information, database, strategies, systems, plans, assets, liabilities, costs, revenues, profits,
organization, officers, directors, employees, or to business in general, in written, physical or electronic form, or if disclosed
orally.
As a bona fide active employee, consultant or credentialed doctor of Asian Hospital & Medical Center, I
understand and hereby agree and acknowledge that:

1. Hospital data and/or information must be maintained strictly confidential;

2. Not to disclose any confidential data, including price or cost of services, and/or information to any person, other than, the
duly authorized active employee(s), consultant(s), credentialed doctor(s) or personnel of AHMC;
3. Use hospital data and /or information in relation to the performance of my tasks, duties and responsibilities;
4. Notify my Department Manager/Director or party concerned in writing for any requests for disclosure of confidential
information by non-duly authorized active employee(s), consultant(s) or credentialed doctor(s) of AHMC, or non-
AHMC personnel or entities;
5. Access to computer systems is granted only to persons who have submitted a written request and have been issued
individual user identification name;
6. Assigned user identification name and password are confidential and may not be shared or disclosed to any other
person or displayed in work areas;
7. Using another employee’s user identification name and password or giving out my user identification name and
password to another person may result in disciplinary action, which may include suspension or termination as
embodied in the AHMC Code of Ethics and/or other related policies;
8. I am directly responsible for the accuracy and completeness of data I have encoded into AHMC’s enterprise-wide
Hospital Information System and other peripheral application systems;
9. Accessing hospital information, such as, but not limited to financial, medical, patient or employment records in manual
or electronic format without legitimate reason and/or approval, constitute a security violation;
10. Prevent unauthorized use of my user identification name and password by logging-out when I have to leave my
computer at the workplace;
11. Allow the authorized Operations personnel to perform audit on my access and usage of AHMC’s computing resources.;
and
12. Return all AHMC’s information, records, materials and properties in my possession, including all confidential
information such as notes, records, database, reports and other documents upon my separation with AHMC.

My signature below indicates I have read and understood the above statements. I understand my non-
compliance may lead to disciplinary action as embodied in the AHMC Code of Ethics and/or other related policies.

Conforme: Noted:

Signature over printed name of Requestor /Date Signature over printed name of Dept. Head or Manager/Date

QF-MIS-010 2205 Civic Drive, Filinvest Corporate City, Alabang, Muntinlupa City, 1780 Philippines
Rev 04 Tel: (632) 771-9000 to 02 • Fax: (632) 876-5710 • Website: www.asianhospital.com
January 2014