Health Declaration Form

To our CCA & Cravings community, we welcome you back into our place. For the safety & health of everyone, we kindly ask you to fill up this digital health declaration form upon entry:

First Name

Last Name

Your Email

Home Address

Area Code

Home Number

Have you worked, visited, or transited to/from any foreign country in the last 14 days?
YesNo

Did you experience any of the following: fever, colds, cough, sore throat, loss of smell and taste, muscle pain, headache, or difficulty in breathing in the last 14 days?
YesNo

Have you worked, visited, or lived in any city in the Philippines that is still under Enhanced Community Quarantine in the last 14 days?
YesNo

Have you been in close contact or exposed to any person suspected of or confirmed with COVID-19 in the last 14 days?
YesNo

Declaration and Data Privacy Consent: The information I have given is true, correct, and complete. I understand that failure to answer any question or giving false answers can be penalized in accordance with the law. I voluntarily and freely consent to the collection and sharing of the above personal information only in relation to CCA Manila & Cravings’ COVID-19 internal protocols in accordance with the Data Privacy Act.