Health Declaration Form - Jackhan Sdn Bhd To protect you and all our staff, we request for your kind cooperation and understanding to duly fill up the declaration form below before you can proceed to make an appointment with us. Thank you. OK Question Title * 1. Please provide your full name: OK Question Title * 2. Please provide your contact information: OK Question Title * 3. Are you showing the following symptoms? (Tick as appropriate) Fever (above 38 degree celsius) Cough Shortness of Breath Sore Throat Runny Nose None of the above Other (please specify) OK Question Title * 4. Have you had or suspected having close contact* with a person who has been diagnosed with COVID-19 and/or issues with Quarantine Order?*close contact means having cared for; having live with, or having had direct contact with respiratory secretions and body fluids of a person with COVID-19 Yes No OK Question Title * 5. Do you have any family members/relatives/friends who have recently returned from overseas in the past 14 days? Yes No OK Question Title * 6. Have you visited/returned from overseas in the past 14 days? Yes No OK Question Title * 7. Kindly select from which showroom (choose one only) you would like to make an appointment with: Ashley Sengkurong Branch Ashley Sg. Tilong Branch Jackhan Jerudong Branch Jackhan Jangsak Branch Jackhan Sg Tilong Branch OK Question Title * 8. Kindly state the Date & Time you would want to make an appointment for:Available appointment time:Monday - Saturday: 9am - 6pmSunday: 9am to 6pmClosed during Friday prayers from 12pm to 2pmPlease take note to set your appointment at least one day before the appointment date.(Answer example: Thursday, 12th August 2021, 2 pm) OK Question Title * 9. Please give us at least 24hrs to review the answers and our staff will follow up with you regarding your appointment. Thank you! ✨*Please take note that all incomplete or incorrect answers will not be entertained. OK DONE