COVID-19 Health and Travel Declaration

Dear Sir/Ma’am,

To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our staff and patients, we require all patients and visitors to fill up this simple screening declaration. Kindly note that we will be collecting personal data for purposes of contact tracing and other response measures during the outbreak of the COVID-19.

Your cooperation is important to help us take precautionary measures to protect you and everyone in this clinic.

1. Name

Full Name in NRIC

First Name

Last Name

2. NRIC/FIN Number

3. Contact Number

4. Temperature

Please approach our staffs for temperature taking

5. Email

6. Are you having cough, sore throat, runny nose, fever, or shortness of breath?

7. Are you currently under Quarantine Order / Stay-Home Notice / LOA / 5-day MC (or supposed to be under QO/SHN/LOA)?

8. Are you in close contact with any confirmed case of COVID-19 infection within the past 14 days?

9. Have you traveled overseas within the past 14 days?

10. Please acknowledge the declaration below

Yes, I declare that all information provided in this form is true, correct and accurate.