Health Declaration - United Medicare Centre

UMC Health Screening Form

Dear Visitor, Due to the outbreak of COVID-19, United Medicare Centre has put in precautionary measures to safeguard the well- being of our residents and staff. We shall therefore appreciate your kind understanding to complete the form and information listed as below to facilitate us to expedite the contact tracing if the need arises.

Date

Time In*

Temperature*

Name*

Email address

Contact No.

Gender*

Male

Female

Vehicle No (If Applicable)

I would like to visit:*

Name of Resident or Staff Whom You Are Visiting*

Resident Ward Level or Department Whom You Are Visiting*

Do you feel unwell? (e.g. fever, respiratory symptoms, cough or shortness of breath*

Yes

No

Have you travelled overseas in the last 14 days? *

Yes

No

Are you currently on Leave of Absence or serving the Stay-Home Notice? *

Yes

No

Declaration*

I hereby declare that the information provided is true and correct to my best knowledge.

Under the Infectious Diseases Act, anyone making a false declaration can be prosecuted.

Are you human?*

This field should be left blank

UMC Health Screening Form

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