Online Declaration Form

Appointment

Find a Condition or Treatment

Find a Doctor

About KKH
Back to Home
Corporate Profile
About KKH
Vision and Mission
Hospital Leadership
Medical Strengths
Medical Highlights
Hospital Milestones
Clinical Outcomes
Personal Data Protection Act
Social Media @ KKH
Newsroom
Press Releases
News Articles
Special Delivery
Procurement
Volunteering at KKH
Calendar of Events
Contact Us
Key Contacts
Appointments
Medical Report
Compliments
Feedback and Enquiries
Check Fake News
In a Contingency
Patient Care
Back to Home
Conditions & Treatments
Find a Doctor
Areas of Care
Find a Doctor
Women's Services
Children's Services
Allied Health Specialties
Nursing
Teleconsultation
Support Groups
Patient Education
Patient Rights and Responsibilities
Your Clinic Visit
Your Hospital Stay
Ward Virtual Tour
E-Services
Make/Change Appointment
Financial Counselling Online
Estimated Bill Calculators
Make Your Payment Online - ePay
MediSave Maternity Package Claims
Request For Medical Report Online
Visitor Information
Directions to KKH
Directions to KKH Children's Emergency & Urgent O&G Centre
Moving around KKH
Visitor Registration
Amenities & Facilities
Contact Us
Research & Innovation

Back to Home
KK Research Centre
Our Researchers
Clinical Trials
Publications
SingHealth Research
Education & Training
Back to Home
Undergraduate
Residency
Continuing Education
Training & Fellowships
Allied Health Specialties
Medical
Nursing
Events & Courses
SingHealth Academy
Careers
Back to Home
Why Choose Us
Career Choices
Doctors
Nurses
Allied Health Professionals
Management and Administration
Ancillary and Support
Job Opportunities
Scholarships & Sponsorships
Contact Us
Giving
Back to Home
Why Give
Finding a Cure
Advancing Medical Education
Helping Our Patients
Appreciating Your Support
Furthering Donor Impact
Get Involved
Make a Gift
Create a Named Fund
Honour a Healthcare Hero
Your Gift at Work
Meet Grateful Patients
Meet Donors Like You
Meet Our Researchers
Be Informed
Make a Gift

Home to skip to the main content on a page to skip to the main content on a page

Home > Online Declaration Form

Online Declaration Form

Page Content

Tags:

; ; ; ; ; ; ; ; ; ; ; ; ; ;

DECLARATION FORM

Date

Institution I intend to go to

I am

Patient Name

Please provide your particulars

Your Name

Your NRIC / FIN / Passport

Mobile No

I am going to

Location Others

Declaration by Patient/Visitor

1. Have you travelled abroad (i.e. to any countries outside of Singapore, excluding Brunei and New Zealand) in the past 14 days?

Yes
No

2. Do you have flu-like symptoms (e.g. fever, cough, runny nose, sore throat or loss of taste / smell, etc.)?

Yes
No

3. Are you currently:
(i) serving Stay-Home Notice (SHN); OR
(ii) serving Quarantine Order (QO) issued by the Ministry of Health (MOH)?
(iii) a Person Under Phone Surveillance (PUPS) by MOH?

Yes
No

4. In the past 14 days:

did you receive a MOH Health Risk Warning SMS or a MOH Health Risk Alert SMS; OR
have you had close contactwith a COVID-19 person?

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.

Please verify that you are not a robot.