Visitor’s Registration Record

Date of visit

Time

Name

Contact no

Est. duration of visit (in hr)

E-mail (optional)

Do you want to receive the visitor's registration record?

SMS

Purpose of the visit

Please select the appropriate box(es):

Staff

Admission

Accompany for consultation

Consultation

Patient visit

Goods delivery

Service maintenance

Others

In line with Government’s updated policy, starting from 00:00 am on March 25, people arriving in Hong Kong who have been to any overseas countries/territories in the past 14 days, regardless of whether they are Hong Kong residents, will be subject to compulsory quarantine.

In respond to the advice from Department of Health regarding visiting policy of private hospitals, all visitors should provide information as below:

Please select the appropriate box(es):

To protect all persons in the hospital, you are not allowed to enter the premise if you fulfil no. 1 screening criterion OR fulfil any of no. 2 – 7 criteria and are unable to provide supporting document and/or a valid negative COVID-19 test report.

The personal data provided will be kept strictly confidential, and will only be used for the purpose of preventing the occurrence or spread of an infectious disease or contamination.

According to the Prevention and Control of Disease Ordinance (Cap. 599), a person commits an offence if the person knowingly given any information that is false or misleading in a material particular.

I declare that the statements made in this form are true, correct and complete to the best of my knowledge and belief.

I understand

1	Do you currently have fever or respiratory symptoms or sudden loss of taste/smell?	Yes No
2	Have you ever been outside of HK in the past 14 days?	Yes No
3	Have you ever visited specified premises in the specified time listed in a compulsory testing notice under the Prevention and Control of Disease (Compulsory Testing for Certain Persons) Regulation (Cap. 599J)?	Yes No
4	Have you been in close contact with any confirmed case in the past 28 days?	Yes No
5	Are you currently under medical surveillance?	Yes No
6	Is/are your family member(s) living with you currently under home quarantine?	Yes No
7	Have you received written direction for compulsory testing under the Prevention and Control of Diseases (Compulsory Testing for Certain Persons) Regulations (Chapter 599J)?	Yes No