Contact Tracing Form

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First Name

Last Name

Address

Email Address

Contact Number:

Temperature

Date of Registration

Time

Branch Visited

Please check if you are new or existing customer.

New

Existing

I hereby authorize DERMCARE to collect and process the data indicated herein for the purpose of contact tracing effecting control of the COVID-19 transmission. I understand that my personal information is protected by RA 10173 or the Data Privacy Act 2012 and that this form will be distroy after 30 days from the date of accomplishment, following the National Archives of the Philippines protocol.