COVID-19 Screening Declaration
For Retail Customers
Full Name
Contact Number
Date of Visit
Are you experiencing any of the following symptoms: fever, cough, sore throat, shortness of breath, loss of taste or smell?
No
Yes
Have you been in close contact with a confirmed COVID-19 case in the last 14 days?
No
Yes
Have you returned from international travel in the past 14 days?
No
Yes
Do you have a current requirement to self-isolate as directed by health authorities?
No
Yes
I declare that the above information is true and correct to the best of my knowledge.
Signature
Date