HEALTH DECLARATION FORM

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

NOTE: Anyone making false declarations can be prosecuted under the Infectious Diseases Act.

Please complete this travel and health declaration on the day of your visit.

Email *

Your name *

Your NRIC/passport number *

Do you have any of the following? *

Fever

Cough or sore throat, running nose or breathing difficulty

Anosmia (partial or complete loss of the sense of smell)

None of the above

Required

Have you travelled or resided (i.e. to any country outside Singapore) in the last 7 days? *

Yes

If you answered "Yes" to the previous question, please specify the country and city you had been in the past 7 days.

Last date in that country

Have you been in close contact with a case of COVID-19 in the last 7 days? *

Yes

Have Antigen Rapid Test (ART) positive in the past 72 hours? *

Yes

Are you currently serving Stay Home Notice (SHN) or Isolation Order? *

Yes

Are you currently on "Health Risk Notice" (HRN) or Daily Antigen Rapid Test (ART) monitoring? *

Yes

If you are on HRN or Daily ART monitoring, please provide today's ART result: *

Not done

Negative

Positive

Have a POSITIVE Antigen Rapid Test (ART) result in the past 72 hours? *

Yes

Have you been diagnosed with COVID-19 via a positive PCR/ART (healthcare administered) swab? *

Yes

If you have answered "yes" to the previous question, what was the date of your COVID-19 infection?

YYYY

I hereby declare that I have answered the above questions truthfully. I understand that anyone making false declarations can be prosecuted under the Infectious Diseases Act. The Infectious Diseases Act is the principal piece of legislation that deals with the prevention and control of infectious diseases in Singapore. The information you provide is important in managing the risk of COVID-19 transmission. A person who knows, or has reason to suspect, that he/she is a case or carrier or contact of COVID-19 shall act in a responsible manner to not expose other persons to the risk of infection. *

I agree

Required

By providing personal data through this declaration form, I authorise PS Tan Digestive & Liver Centre to collect, use, process and disclose personal data provided for the purpose of verifying your identity, screening your health status and maintaining records of visitors to PS Tan Digestive & Liver Centre for contact tracing purposes, to ensure our safety and security. The information collated will be securely discarded after 1 month. *

I agree

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms