Picasso Customer Health Declaration Form
We are conducting a simple screening questionnaire for all our customers.
There is no cause for any panic. All is swell and great at the moment! We just want to do our best to prevent any community spread within our premises as best as we can. Information you provide will be treated with strict confidence and used only for the purpose of contact tracing when needed by MOH.
Name *
Your answer
Phone Number *
Your answer
Address *
Your answer
Email
Your answer
Have you traveled to Mainland China / Hong Kong in the past 14 days? *
Please provide details of the countries you have visited / stopped over while travelling in the past 14 days? (If not applicable, you can ignore this question)
Your answer
Were you (or any family members) visited by any friends or relatives from Mainland China / Hong Kong in the past 14 days?
When was the date of their visit? (input NA if not applicable) *
Your answer
If you have the following symptom(s), please tick the relevant boxes. *
Required
Has MOH and/or doctors evaluated whether you can be resume normal activities? * *
Submit
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