Step 1 Data Privact Act

Dear Patient Partner,
YOU ARE REQUIRED TO PROVIDE TRUTHFUL INFORMATION ABOUT YOUR HEALTH CONDITION AND POSSIBLE EXPOSURE.
Pursuant to the provisions of the Data Privacy Act of 2012, I hereby give my free and voluntary consent for Riverside Medical Center, Inc., (owner and operator of the Dr. Pablo O. Torre Memorial Hospital), its staff, personnel, agents or authorized representatives for the collection, use, sharing and transmittal by any means and processing of my personal information, medical information or privileged information as set out in my Riverside Medical Center, Inc. Data forms, records, medical diagnosis, medical results and findings, and/or any other document or media provided by me or already possessed by Riverside Medical Center, Inc., for purposes relevant to my consultation, diagnosis, treatment, tests or for any other instances mandated by law.

Step 2 Personal Infomation

Lastname *
Firstname *
City *
Cellphone No. *
Gender *
Birthdate *
format MM/DD/YYYY
I'm visiting as a:
Location of Visit

Step 3 Health Check

 
RMCI COVID-19 Self-Checklist
1. Do you have a Fever (temperature over 37.8C) without having taken any fever reducing medications?
Yes No
 
2. Do you have a Loss of Smell or Taste?
Yes No
 
3. Do you have a Cough?
Yes No
 
4. Do you have Muscle Aches?
Yes No
 
5. Do you have a Sore Throat?
Yes No
 
6. Do you have Shortness of Breath?
Yes No
 
7. Do you have Chills?
Yes No
 
8. Do you have a Headache?
Yes No
 
9. Have you experienced any gastrointestinal symptoms such as nausea/vomiting, diarrhea, loss of appetite?
Yes No
 
10. Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19?
Yes No
 
11. Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?
Yes No
 
12. Have you been Swabbed for RT-PCR Test?
Yes No

Step 4 Confirm Your Details

PATIENT'S / VISITOR'S / COMPANION'S CONSENT and / or DESIGNATED REPRESENTATIVE'S ASSENT

By filling up this form, I confirm that:

I have been informed that Riverside Medical Center, Inc. is undertaking these measures to ensure that the well-being and protection of everyone, myself included, is prioritized. I understand that data about COVID-19 is constantly changing and despite the diligent efforts of Riverside Medical Center, Inc. to minimize transmission, there is still a risk of acquiring the infection.

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.

For any of your questions and concerns, please call (034) 705-0000.