COVID FORM

12:03 PM

COVID FORM

Covid Health Declaration

To prevent the spread of novel coronavirus (Covid-19) in our community and reduce the risk of exposure to our staff and visitors, we require you to complete this screening questionnaire prior to entering Sole To Soul Dance Studio premises.

Covid Health Declaration Form

Full Name :
Nationality :
Gender :
Age :
NRIC / Passport (Non-Malaysian) :
Contact Number :
Address :
Email Address :
Have you been to any area or countries of COVID-19 as indicated by WHO over the past 14 days? (Yes / No)
If "Yes", state country have you visited :
Date of departure from the said country :
Have you been in close contact with person being infected, suspected or diagnosed with COVID-19? (Yes / No)
Name your relationship with the said person and your last contact date :
Have you been admitted to any hospital or tested positive for COVID-19 and recovered? (Yes / No)
If "Yes", where were you admitted to?
And when were you discharged?
Please state wether you've experienced / are experiencing any of the following (Fever / Cough / Shortness of Breath / Flu / Persistent Pain In Chest) :

I declare all the above to be true and correct. By submitting this declaration form, I agree to the collection, use, and disclosure of my personal information above by Sole To Soul Dance Studio for the purposes of a precautionary measure against COVID-19 Acute Respiratory Disease in the company’s premises.

If you need further assistance or would like to speak to us directly, call +603-7806 5852 or WhatsApp to +6012-222 3700.

TOP

Sole To Soul Dance Studio Petaling Jaya (PJ) Malaysia

COVID FORM