Visitor’s Registration Record

Submission Successful

Please show the QR code below to our staff upon entry to the hospital.

Date of visit:

2021-08-04

Time of visit:

16:58:31

Name:

Contact no:

Purpose of the visit:

Details

Do you currently have fever or respiratory symptoms or sudden loss of taste/smell?

Have you ever stayed in / visited any place(s) outside of HK in the past 21 days?

Have you been in close contact with any confirmed case in the past 28 days?

Are you currently under compulsory quarantine / home quarantine period ordered by the Government under the Prevention and Control of Disease Regulation (Cap. 599)?

Are you currently under the designated period of compulsory testing ordered by the Government or medical practitioner under the Prevention and Control of Disease (Compulsory Testing for Certain Persons) Regulation (Cap. 599J)?

Are you currently under self-monitoring period ordered by the Government under the Prevention and Control of Disease Regulation (Cap. 599)?

Are you the designated person that fulfilling certain criteria for exemption from quarantine ordered by the Government under section 4(1) of the Compulsory Quarantine of Certain Persons Arriving at Hong Kong Regulation (Cap. 599C) (the Regulation), made under the Prevention and Control of Disease Ordinance (Cap. 599)?

Visitor’s Registration Record

Date of visit

Time of visit

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:

Staff

Admission

Consultation

Booked with Specialist Outpatient Clinic’s appointment

Other consultation

Carer

Accompany for consultation

Patient visit

Ward

Bed no.

Goods delivery

Department

Service maintenance

Department

Others

Please specify

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

Please select the appropriate box:

1	Do you currently have fever or respiratory symptoms or sudden loss of taste/smell?	Yes No
2	Have you ever stayed in / visited any place(s) outside of HK in the past 21 days?	Yes No
3	Have you been in close contact with any confirmed case in the past 28 days?	Yes No
4	Are you currently under compulsory quarantine / home quarantine period ordered by the Government under the Prevention and Control of Disease Regulation (Cap. 599)?	Yes No
5	Are you currently under the designated period of compulsory testing ordered by the Government or medical practitioner under the Prevention and Control of Disease (Compulsory Testing for Certain Persons) Regulation (Cap. 599J)?	Yes No
6	Are you currently under self-monitoring period ordered by the Government under the Prevention and Control of Disease Regulation (Cap. 599)?	Yes No
7	Are you the designated person that fulfilling certain criteria for exemption from quarantine ordered by the Government under section 4(1) of the Compulsory Quarantine of Certain Persons Arriving at Hong Kong Regulation (Cap. 599C) (the Regulation), made under the Prevention and Control of Disease Ordinance (Cap. 599)?	Yes No

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

Infection Prevention and Control Department

Version 13 | Effective: 28 Jun 2021