{"id":41,"date":"2020-09-03T13:31:00","date_gmt":"2020-09-03T05:31:00","guid":{"rendered":"https:\/\/migrate.cghmc.com.ph\/booking\/drive-thru\/?page_id=41"},"modified":"2020-10-16T10:26:48","modified_gmt":"2020-10-16T02:26:48","slug":"health-check","status":"publish","type":"page","link":"https:\/\/cghmc.com.ph\/booking\/drive-thru\/health-check\/","title":{"rendered":"Health Declaration Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_17' style='display:none'><div id='gf_17' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Health Declaration Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_17'  action='\/booking\/drive-thru\/wp-json\/wp\/v2\/pages\/41#gf_17' data-formid='17' novalidate>\n        <div id='gf_progressbar_wrapper_17' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_green' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_green percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_17_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_17_8\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent font-size:16px gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_8.1' id='input_17_8_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_17_8\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_17_8_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_8.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_8.3' value='2' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_17_8' tabindex='0'>I declare under violation of Republic Act 11332 that i have NOT been a COVID patient nor have had any close contact with a positive or suspected COVID patient one have displayed any signs and symptoms under#1 ang I have truthfully disclosed the absence of the above signs and symptoms as required under REPUBLIC ACT No. 11332 (An Act Providing Policies and Prescribing Procedures on Surveillance and Response to Notifiable Diseases, Epidemics, and Health Events of Public Health Concern)<\/div><\/li><li id=\"field_17_9\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_9'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_9' id='input_17_9_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_17_9_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_17_9' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/cghmc.com.ph\/booking\/drive-thru\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_17_9_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_17_9_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_17_9_data' name='input_17_9_data' value=''><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_17_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_2' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_17_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_17_2\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_17_2'>\n                            \n                            <span id='input_17_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_17_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_17_2_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.4' id='input_17_2_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_17_2_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_17_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_17_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_17_22\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_22'>Mobile No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_17_22' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_11' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_17_11' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_3' class='gform_page' data-js='page-field-id-11' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_17_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_17_1\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you have the following signs and symptoms of Covid-19 infection, such as:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_17_1'><li class='gchoice gchoice_17_1_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.1' type='checkbox'  value='gquiz115c5db58'  id='choice_17_1_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_1_1' id='label_17_1_1' class='gform-field-label gform-field-label--type-inline'>I have Cough or Colds<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_1_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.2' type='checkbox'  value='gquiz16396c0c3'  id='choice_17_1_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_1_2' id='label_17_1_2' class='gform-field-label gform-field-label--type-inline'>I have  Difficulty in breathing or shortness of breath<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_1_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.3' type='checkbox'  value='gquiz188a8eda0'  id='choice_17_1_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_1_3' id='label_17_1_3' class='gform-field-label gform-field-label--type-inline'>I have Fever of more than 37.5 C<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_1_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.4' type='checkbox'  value='gquiz1a1f24e50'  id='choice_17_1_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_1_4' id='label_17_1_4' class='gform-field-label gform-field-label--type-inline'>I dont have any sympthoms<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_12' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_17_12' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_4' class='gform_page' data-js='page-field-id-12' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_17_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_17_18\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" ><label class='gfield_label gform-field-label' >Travel History<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_18'>\n\t\t\t<li class='gchoice gchoice_17_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='gquiz188e83ca6f'  id='choice_17_18_0'    \/>\n\t\t\t\t<label for='choice_17_18_0' id='label_17_18_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='gquiz18fdd03cc0'  id='choice_17_18_1'    \/>\n\t\t\t\t<label for='choice_17_18_1' id='label_17_18_1' class='gform-field-label gform-field-label--type-inline'>If Yes, Where and When?<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_16'>Where and When?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_17_16' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_13' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_17_13' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_5' class='gform_page' data-js='page-field-id-13' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_17_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_17_6\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" ><label class='gfield_label gform-field-label' >Exposure to a positive COVID-19 patient at home or in a workplace<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_6'>\n\t\t\t<li class='gchoice gchoice_17_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='gquiz648381c18'  id='choice_17_6_0'    \/>\n\t\t\t\t<label for='choice_17_6_0' id='label_17_6_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='gquiz64d70b720'  id='choice_17_6_1'    \/>\n\t\t\t\t<label for='choice_17_6_1' id='label_17_6_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_14' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_17_14' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_6' class='gform_page' data-js='page-field-id-14' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_17_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_17_19\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gquiz-field \"  data-field-class=\"gquiz-field\" ><label class='gfield_label gform-field-label' >Covid swab test done:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_19'>\n\t\t\t<li class='gchoice gchoice_17_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='gquiz1982a61658'  id='choice_17_19_0'    \/>\n\t\t\t\t<label for='choice_17_19_0' id='label_17_19_0' class='gform-field-label gform-field-label--type-inline'>COVID negative swab \/ No Covid swab done<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_17_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='gquiz19c728a417'  id='choice_17_19_1'    \/>\n\t\t\t\t<label for='choice_17_19_1' id='label_17_19_1' class='gform-field-label gform-field-label--type-inline'>COVID positive swab<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_15\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below 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