Doctor Using Digital Tablet

DECLARATION FORM

Declaration by Patient/Visitor

The information you provide is important in managing the risk of COVID-19 transmission. The Infectious Diseases Act requires a person who has reason to suspect that he is a case or carrier of COVID-19, or has had contact with a person with COVID-19, to act in a responsible manner to not expose other persons to the risk of infection by the disease.

Have you travelled abroad (i.e. to any countries outside of Singapore) in the past 14 days?
Do you have flu-like symptoms (e.g. fever, cough, runny nose, sore throat, etc.)?
Did you, in the past 14 days, come in close contact with someone who (i) Is a confirmed COVID-19 case; OR (ii) Is part of a COVID-19 cluster?
Are you currently serving or in contact who are Quarantine Order (QO), Leave of Absence (LOA) or Stay-Home Notice (SHN)?
Did you come in contact with someone who has returned from overseas in the past 14 days?
 

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Novena Medical Center, Singapore 307506

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