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Health declaration form

All fields are required.

NB: It is an offence under the Infectious Diseases Act to provide false declaration.

Have you been diagnosed with COVID-19 in the last 7 days?

Yes No

Do you have any of the following symptoms:

No Fever Cough Shortness of breath Runny nose Sore throat

Did you have contact with any case of COVID-19 in the last 7 days?

Yes No

Name as in NRIC

Acknowledgement:

I acknowledge that I’ll turn up for my appointment unaccompanied. Only one accompanying adult will be allowed for minors.

...

Declaration:

I hereby declare that I have answered the above questions truthfully.