Health Declaration Form - Jackhan Furniture Sdn Bhd

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To protect you and all our staff, we request for your kind cooperation and understanding to duly fill up the declaration form below before you can proceed to make an appointment with us. Thank you.

Untitled title

Please provide your full name: *

Please provide your IC number: *

Please provide your home address: *

Please provide your contact number: *

Are you showing the following symptoms? *

(Tick as appropriate)

Fever (above 38 degree celsius)

Cough

Shortness of Breath

Sore Throat

Runny Nose

None of the above

Other:

Required

Have you had or suspected having close contact* with a person who has been diagnosed with COVID-19 and/or issues with Quarantine Order? *

*close contact means having cared for; having live with, or having had direct contact with respiratory secretions and body fluids of a person with COVID-19

Yes

Do you have any family members/relatives/friends who have recently returned from overseas in the past 14 days? *

Yes

Have you visited/returned from overseas in the past 14 days? *

Yes

Kindly state the Date & Time you would want to make an appointment for: *

Available appointment time: Monday - Saturday: 9am - 7pm Sunday: 10am - 5pm Please take note to set your appointment at least one day before the appointment date. (Answer example: Saturday, 11th March 2020, 2 pm)

Please give us at least 24hrs to review the answers and our staff will follow up with you regarding your appointment. Thank you! ✨

*Please take note that all incomplete or incorrect answers will not be entertained.

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