Health declaration form
All fields are required.
Do you have any of the following symptoms:
Shortness of breath
Have you been overseas in the last 14 days?
If yes, please indicate all the countries that you have travelled to in the last 14 days.
Have you been issued with HRA, HRW or SHN?
Did you have contact with any case of COVID-19 in the last 14 days?
Did you visit any hospital in the last 14 days?
Do you work or live in a communal setting eg. dormitory, nursing home?
I acknowledge that I’ll turn up for my appointment unaccompanied. Only one accompanying adult will be allowed for minors.
I hereby declare that I have answered the above questions truthfully.
NB: It is an offence under the Infectious Disease Act to provide false declaration.