HEALTH DECLARATION FORM
Important Reminder:

Kindly complete this health declaration form honestly. Failure to answer or giving false
information is punishable in accordance with Philippine laws

Please e mail the copy of valid id at:    
 sales@oriental-zen-suites.com

Accomplish and send the duly filled up form before actual arrival at Oriental Zen Suites
Full Name of Guest  :
Civil Status   :
Male
Female
Married
Single
Residential Address :
Contact Number  :
E-mail Address :
Date of Birth  :
Occupation   :
Purpose of Travel  :
Is the Purpose of Stay for Quarantine?
Yes
No
Do you have travel history for the last 14 day? :
Yes
No
If yes,  please fill up below the necessary details:
Arrival Date  :
Flight No. :
Port of Origin :
Countries Visited for the last 14 days  :
Cities/Municipalities Visited in the
Philippines for the last 14 days  :
Please check if you have any of the following at
present or during the past fourteen (14) days :
Yes
No
New and Persistent Cough
Shortness of Breath or Difficulty in Breathing
Fever
Sore Throat
Body Weakness
Unexplained Bruising or Bleeding
Health and Safety-Related Questions :
Have you been in contact with  anyone  in the last 14
days who is experiencing this COVID-19 symptoms?
Yes
No
If yes, please state the name, contact details,
date  and  address of  person in contact with.
Name of Person :
Address  :
Contact Details :
Have you been in contact with anyone who has since tested positive for Covid-19?
Yes
No
If yes,

please state the name, contact details, date and address of person in contact with.
Name of Person :
Address  :
Contact Details :
Have you undertaken any COVID Test?
Yes
No
If Yes, kindly provide the following information :
Tyoe of Covid Test  :
RT-PCR
Rapid Antibody Test
Date of Covid Testing :
Result   :

Oriental Zen Suites Temperature Check Policy:

I’m willing to take a body temperature check upon entering the building. And I completely
understand that Oriental Zen Suites will  not permit me to enter the building premises if I
have the following symptoms of COVID-19 listed below:
Yes
No
Body Temperature:
Shortness of Breath
Loss of Sense of Taste or Smell
Dry Cough
Runny Nose
Sore Throat
I fully understand, read, and completed this questionnaire truthfully. I agree that this

constitutes   full disclosure   and   that  it  supersedes any previous verbal or written

disclosures. I understand  that  this  document is to provide the health condition and

experience of guest before and during the visit to Oriental Zen Suites.
Yes , I completely understand.
Signature
Data Privacy Notice:

Oriental Zen Suites, in line with Republic Act 10173 or the Data Privacy Act of 2012, is committed
to protect  and  secure  personal  information  obtained in the performance of duties. Oriental  Zen
Suites  collects  the  above  personal information  relevant  in  the  advancement of protocols and
precautionary measures against COVID-19 Acute Respiratory Disease.. The collected information
will be  kept  /  stored  and accessed  only by authorized personnel and will not be shared wit any
outside  parties  unless  the  disclosure  is  required  by, or in compliance with applicable laws and
regulations.
    Oriental Zen Suites