Health Declaration Form

Dear Visitor,

Given the evolving situation in COVID-19 (Coronavirus Disease 2019), we are taking the necessary measures to ensure the safety and well-being of our visitors, staff and the community. As such, we request that you take a couple of minutes to fill in this form. Information collected is strictly confidential and will only be used for contact tracing when needs arise

Thank you for your cooperation.

Full Name as per NRIC/Passport*

Contact number*

Last 4 digits of your NRIC (SXXXX412K)/ FIN (GXXXX412K)*

Date of visit*

Time of visit*

Are you currently feeling unwell or having any respiratory symptoms (such as fever, cough, sore throat or runny nose)?*

YesNo

Are you currently under the Home Recovery Programme (HRP)?*

YesNo

Within the last 14 days, have you had contact with a COVID-19 confirmed case, been issued a Health Risk Notice (HRN), or served in the Home Recovery Programme (HRP)?*

YesNo

Terms & Conditions

I understand that I am opting for an elective treatment/procedure that is not urgent and may not be medically necessary. I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, the Ministry of Health (MOH) recommends social distancing.
I recognize that Dr. KIM MICHAEL JAMES and all the staff at Aeon Medical and Aesthetic Centre are closely monitoring this situation and have put in place reasonable preventive measures aimed to reduce the spread of COVID-19. However, despite the preventive measures, and given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 in proceeding with this elective consultation/treatment/procedure.
I understand I have the option to defer my consultation/treatment/procedure to a later date.
I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure.
I understand that I am to postpone my appointment if I have any respiratory symptoms before coming to the clinic.
I understand that I can only enter the clinic if I have completed and submitted this declaration/consent form.
I understand and have read the safety measures stated on the clinic website and agree to them in full.
I understand that the management reserves all rights to refuse entry for the safety of the patients and staff if deemed necessary to prevent Covid-19 transmission.

I hereby declare that I have read and agree to the terms and conditions stated above*.