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AkQuire HDC

This document is a health declaration card completed by Jeanray Gonzales upon arrival in the Philippines from an international flight. It contains his personal details like name, passport number, contact information, flight details, residence address, and health profile answering questions about symptoms and exposure to COVID-19. By submitting the form, he consents to sharing this information for contact tracing purposes and confirms that all information provided is true under Philippines law.

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Jeanray Gonzales
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55 views1 page

AkQuire HDC

This document is a health declaration card completed by Jeanray Gonzales upon arrival in the Philippines from an international flight. It contains his personal details like name, passport number, contact information, flight details, residence address, and health profile answering questions about symptoms and exposure to COVID-19. By submitting the form, he consents to sharing this information for contact tracing purposes and confirms that all information provided is true under Philippines law.

Uploaded by

Jeanray Gonzales
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

Province of Aklan
HEALTH DECLARATION CARD

Tourists
-- Please read before proceeding --
In compliance with RA 10173 or Data Privacy Act of the Philippines, the personal information you will be providing in this
form shall not be used for other purposes except for COVID-19 contact-tracing activities

497f5ad5-ff88-4e3a-9811-ae0386ee2819 Arrival Date (yyyy-mm-dd): 2022-01-08

Email: [email protected] Contact No: 09065277693

Passport No/Valid ID Type & No: 0160664

Name: First Name


JEANRAY
Middle Name
BABAAN
Last Name
GONZALES
Nationality: FILIPINO Sex: M Birthdate (yyyy-mm-dd): 1996-08-21

Flight/Bus Number/Vessel Name: Z2 219 Seat No: NA

Residence Address Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): 28 DULONG BAYAN

Municipality/City Province Region


SAN JOSE BULACAN REGION III
DEL MONTE
Country(ies) worked, visited and transited in the last 30 days.

PH

HEALTH PROFILE
1. Have you been sick (cough, difficulty breathing, colds, sore throat, fever) in the past 30 days? [ ] Yes [✓]No

2. Have you been exposed to a confirmed case of COVID-19 ? days? [ ] Yes [✓]No

3. Have you been tested positive for COVID-19 using RT-PCR Test ? [ ] Yes [✓]No

Upon submitting, I am providing consent to sharing my information for contact tracing purposes, I confirm that the information I have
given is true, correct and complete and that I understand failure to answer any question may have serious consequences under
Philippines laws. (Article 171 and 172 of the Revised Penal Code of the Philippines)

Signature
https://www.touristboracay.com/ohdc.aspx?id=497f5ad5-ff88-4e3a-9811-ae0386ee2819 1/8/22, 8 48 AM
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