Hepatitis C is a silent liver disease that may lead to Cirrhosis and/or Liver Cancer.

Are you at risk? Register and find out here!


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Last Name: *
Gender: *
Birthday: *
Marital Status: *
City of Residence: *
Zip Code: ( Optional )
Mobile Number: *
+639
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1. Had blood transfusion or organ transplant before 1995 *
2. Shared needle/Injected Drug even once *
3. On hemodialysis for more than 6 months *
4. Born to a mother with Hepatitis C *
5. Have you ever had history of being told to have evidence of liver diseases *


6. Have you tested positive for HIV infection *
7. Have Tattoo on the body or eyebrows *
8. Do you have a family member with liver cancer *
9. Do you have a family member with Hepatitis B or C *
10. Have you ever had sex with a male partner who has had sex with another male *
11. Shared razors or nail clippers together with others (Barbershop/Nail Salon setting) *

Waiver Agreement :

To continue, you will be asked to disclose personal information, including medical information or history, for the benefit of research and testing for hepatitis B and C. We will not disclose information obtained from you to third parties. Except for disclosure only to the relevant personnel.


Please note, however, that data transmission via the Internet may not be secure due to data leaks. Although we have the goal of keeping your information confidential. However, we can not guarantee that such information will not leak through the Internet, so it is your responsibility to monitor and prevent the leakage of data from the Internet. Once we have received your information in the database. We will use strict methods to keep your information up to date.


If you are concerned about the leakage of your data. You may consider disabling this site.



Attention:

Doctors are the best people to guide you. The information provided in this document does not replace your doctor's medical advice. Consult your physician or qualified health care provider if you have questions about your medical condition.


      The form must be completed before the Hepatitis B or C screening is performed.
      If you experience any of these risk factors, please be tested for hepatitis B or C.
      Recommended tests on risk factors and does not mean that people are infected.