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DECLARATION FORM
Institution I intend to go to
Jurong Community Hospital
Jurong Medical Centre
Ng Teng Fong General Hospital
I am
Patient
Accompanying a patient
Visitor
Please provide your particulars
Your Name
Your NRIC / FIN / Passport
NRIC / FIN
Passport / Others
Patient Name
Patient NRIC / FIN / Passport
NRIC / FIN
Passport / Others
Mobile No
I am going to
Specialist Outpatient Clinics
Wards
Pharmacy
Radiology
Others (please specific)
Outpatient Clinics
Consultation
Medical Services
Dental Services
Diagnostic Services
Pharmacy Services
Pediatrics Services
Financial Counselling Services
Payment/Appointment
Location Others
Clinic Name
Date
Declaration by Patient/Visitor
1. Do you have a fever, cough, shortness of breath, blocked or runny nose, sore throat or cannot smell?
Yes
No
2. Have you had close contact with someone with COVID-19 in the last 14 days?
Yes
No
3. Have you travelled outside of Singapore in the last 14 days or returned from UK and/or South Africa in the past 21 days?
Yes
No
4. Are you staying in a dormitory? (for Work Permit Holders)
Yes
No
5. Are you working in occupations or environment with risk of exposure to COVID-19 cases? Eg. Healthcare, Dormitory, Isolation/ Quarantine/ Community Care facilities or Ambulance/ dedicated patient transport etc
Yes
No
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.
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