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?
Do you have any of the following symptoms:
Shortness of breath
Did you have contact with any case of COVID-19 in the last 7 days?
Name as in NRIC
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.