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Name *

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Last

have of shortness

Date of Visit (DD/MM/YYYY) *

In the last 14 days, have you experienced any of the following: fever, cough, sore throat, shortness of breath, or loss of taste/smell?

• Yes
• No

In the last 14 days, have you been in close contact with anyone confirmed or suspected to have COVID-19?

• Yes
• No

In the last 14 days, have you traveled outside Singapore?

• Yes
• No

Declaration *

• I declare that the information provided above is true and accurate to the best of my knowledge.

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Please DO NOT SUBMIT this declaration form if any for the above is “NOT TRUE”.

We regret that we are unable to provide service should any of the above is “NOT TRUE”.

*Please call us immediately at +65 8759 9120 should there be any last minute changes to the declared conditions above.