Healthcare Facility Visitor Security Clearance Form
Visitor Information
Full Name
ID/Passport Number
Contact Number
Email Address
Visit Details
Date of Visit
Time In
Time Out
Person/Patient Visiting
Relationship to Patient
Purpose of Visit
Health & Security Declarations
Items Being Brought Inside
Have you experienced any symptoms (e.g., fever, cough, etc.)?
Recent Contact with Infectious Diseases?
Authorization Use Only
Approved By (Staff Name & Signature)
Clearance Status
Approved
Denied