VSMMC - Online Swab Registration

Clinical Information

Please fill in required fields *

Date of Onset Illness

Are you pregnant?

Yes

Last Menstrual Period

High-risk pregnancy?

Yes

Chest Imaging findings suggestive of COVID-19

Imaging Done (Check all that apply)	Results
Chest radiography	Normal Hazy opacities, often rounded in morphology, with peripheral and lower lung distribution Pending Other findings, specify
Chest CT	Normal Multiple bilateral ground glass opacities, often rounded in morphology, with peripheral and lower lung distribution Pending Other findings, specify
Lung ultrasound	Normal Thickened pleural lines, 8 lines (multifocal, discrete, or confluent), consolidative patterns with or without air bronchograms Pending Other findings, specify
None

Exposure History

Please fill in required fields *

History of exposure to known probable and/or confirmed COVID-19 case 14 days before the onset of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection

Yes

Unknown

Date of Last Contact

Have you been in a place with a known COVID-19 community transmission 14 days before the onset of signs and symptoms? OR if Asymptomatic, 14 days before swabbing or specimen collection?

Yes

Unknown Exposure

IF Yes, specify place (Check all that apply, provide details such as name of establishment, transport service, venue, location etc. and date of visit)

Place Visited	Details	Date of Visit

Travel History

Please fill in required fields *

History of travel/visit/work in other countries with a known COVID-19 transmission 14 days before the onset of signs and symptoms

Yes

Country of Exit

Airline/Sea Vessel

Flight/Vessel Number

Date of Departure

Date of Arrival in PH

History of travel/visit/work in local place with a known COVID-19 transmission 14 days before the onset of signs and symptoms

Yes

Place of Origin

Airline/Sea Vessel/Bus line/Train

Flight/Vessel Number/Bus No.

Date of Departure

Date of Arrival in the current

List the names of persons who were with you two days prior to onset of illness until this date and their contact numbers.
*If asymptomatic, list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers.

Name	Contact Number

For Additional Close Contact (Include All Household Contacts)

Name	Contact Number	Exposure Setting (ex. Household,Work etc.)

DATA PRIVACY NOTICE

Vicente Sotto Memorial Medical Center respects personal data privacy. We are at the forefront of not only implementing but complying with the Data Privacy Act of 2012. Similarly, we would like to inform you regarding the way we would use your personal data. We recommend you to read this privacy policy so that you understand our approach towards the use of your personal data.

By submitting your personal data to us, you will be treated as having given your permission – where necessary and appropriate – for disclosures referred to in this policy.

1. Commitment to uphold Privacy of our data subjects. In line with our commitment to provide quality health care services, the protection and confidentiality of your personal data are our primary concern consistent with the requirements of the Data Privacy Act of 2012, its Implementing Rules and Regulations, National Privacy Commission issuances, and other relevant laws.

This statement provides in brief the manner we collect and process your personal data every time you visit our portal, and avail of our testing services.

2. What we collect from you. With your consent, we collect your personal data, depending on page(s) you visit, which may include:

a. Complete Name

b. Age, sex

c. Date of Birth

d. Address

e. Email address

f. Contact Details; telephone, mobile number

g. Occupation

h. Civil status

i. Nationality

j. Passport No.

FOR OFWS:

k. Address outside the Philippines

l. Travel history

m. Exposure history

n. Clinical Information (disposition at the time of report, date of admission/consultation, signs/symptoms)

o. Medical history of other illness

p. The results of any laboratory tests/ chest X-ray and ancillary services which you provide; and,

q. Any other information that will assist us in providing you with better health care.

3. Why we collect your personal data.

The collected personal information is utilized solely for documentation and processing purposes within VSMMC and is not shared with any outside parties. We use your personal data for the following purpose/s:

a. To enable VSMMC to provide appropriate action and response for your samples to be tested.

b. For purposes required by law and related issuances.

4. Sharing your personal data. We share your personal data with third parties on the following circumstances:

a. You have consented to the sharing thereof;

b. As prescribed by law and applicable issuances related to testing results; or

c. For the Department of Health and Local Government Units for surveillance and contact tracing.

5. Security of your personal data.

We have implemented technology and policies with the objective of protecting your privacy from unauthorized access and improper use and will update these measures as new technology becomes available, for your protection, and for the maintenance of its integrity, availability and confidentiality of the personal data.

This medical center upholds the rights of data subjects under Data Privacy Act of 2012.

6. Contact Information

For your concerns regarding data privacy, you may reach our Data Protection Officer at dpo@vsmmc.doh.gov.ph or call 0920-970-6361.

I Agree to the Terms and Conditions and the Privacy Policy