I, expressly give my consent to and its subsidiaries to collect, process, store, retain, update, retrieve my personal information and sensitive personal information indicated in Physician Request Form for COVID 19 Test.

• Contact Information, such as name, address, contact number, email address, age, sex, and other contact details.
• Personal information such as date and place of birth, nationality, citizenship, civil status, occupation, passport, government-issued IDs.
• Travel History such as country of exit, airline, flight/vessel, date departure/arriva
• Clinical information such as history of other illness, current medication or treatment
• Employment information examples: contracted agency, corporation, household.

I consent and authorize to conduct a COVID-19 Diagnostic Test involving the collection sample through a nose and throat swab.

By authorizing to conduct a COVID-19 Diagnostic Test, I am extending my consent to share my Laboratory Result and / or Certification Copy with my GP and to the following company, agency, and or Individual.

I understand that the test result may be used and shared with third parties for statistical and auditing purposes, and I understand that this is not considered personal data as I will not be identified in any report.

I understand that there are risks associated with undergoing any COVID-19 Test to include minor swabbing trauma such as nasal bleeding/ irritation. I accept that as with any COVID-19 Test, there is a potential for false negative COVID-19 Test Result.

I understand that a Positive/ Detected and/or Negative/ Not Detected Test is not an indication that I am immune t o COVID-19, and therefore, I will follow strict protocol and behave as if I might contract or transmit the infection.

I will assume complete and full responsibility to take appropriate action with regard to my test result. I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

I understand that or any third party does not accept potential liability arising from this COVID-19 Test, to the extent that is permitted by law, to include but not limited to any potential liability arising from any minor swabbing trauma such as nasal bleeding/ irritation and/ or false positive or false negative test results. I understand that neither nor any third party accepts liability for any missed flights/ ferries/ travel accommodation due to late or inaccurate test results.

I agree to share my personal information provided in the necessary paperwork to the , the vaccine distributor, and the Pasay City Health Office, for the purposes of data processing relating to COVID-19.

* Note: Please close/exit Consent Form Page, if you refuse/object to collect, process, store, retain, update, retrieve your personal information and sensitive personal information. Thank you.