Appointment form
This serves as a tentative appointment confirmation. We will still get in touch to confirm your appointment. This form also applies for visitors and accompanying persons.
I am
*
Patient
Accompanying a patient
If you are accompanying a patient, kindly write the full name of the patient here.
Appointment Date
*
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Email
*
example@example.com
Have you ever visited us?
*
Yes
No
Preferred Clinic?
EEC @ Mt Alvernia Hospital
EEC @ Mt Elizabeth Novena Hospital
EEC @ Mt Elizabeth Orchard Hospital
EEC @ Parkway East Hospital
EEC @ Royal Square at Novena
EEC @ KAP (King Albert Park) Residences Mall
EEC @ Westgate Mall
What is the purpose of your last visit?
Have you travelled abroad (i.e. to any countries outside of Singapore) in the past 14 days?
*
Yes
No
Do you have flu-like symptoms (e.g. fever, cough, runny nose, sore throat or loss of taste / smell, etc.)?
*
Yes
No
Are you currently serving:(i) Stay-Home Notice (SHN); OR(ii) Quarantine Order (QO) issued by the Ministry of Health (MOH)?
*
Yes
No
Have you been admitted to or visited Tan Tock Seng Hospital (TTSH)’s Inpatient Wards from 18 April 2021 OR Have you visited TTSH A&E on 18 or 19 April 2021?
*
Yes
No
Please verify that you are human
*
The information you provide is important in managing the risk of COVID-19 transmission. The Infectious Diseases Act requires a person who has reason to suspect that he is a case or carrier of COVID-19, or has had contact with a person with COVID-19, to act in a responsible manner to not expose other persons to the risk of infection by the disease.
Submit
Should be Empty: