MEDICAL DECLARATION FORM

THIS IS IMPORTANT DOCUMENT, YOUR INFORMATION IS VITAL TO ALLOW HEALTH AUTHORITIES CONTACT YOU TO PREVENT COMMUNICABLE DISEASES

Warning: Declaring false information is a violation of Vietnamese law and may be subject to criminal handling

Gate (*)

Full name (*)

Year of Birth (*)

Gender (*)

Nationality (*)

Passport number or other legal document (*)

Travel information (*) Plane Ship Car Other (clarify)

Transportation No. (*)

Seat No. (*)

Departure date (*)

Immigration date (*)

Place of departure (province/country)

Country / Region (*)

Province (*)

Place of destination (province/country)

Country / Region (*)

Province (*)

In the past 14 days, which province / city / territory / country have you been to? (*)

Contact address in Vietnam

Province (*)

District (*)

Ward (*)

Staying address (*)

Phone number you will use in Vietnam (Is Roaming number or Vietnam number)

Phone (*)

If you have any of the followings at present or during the past 14 days (until the date of entry/exit/transit)? (*)

Symptoms	Yes	No
Fever (*)
Cough (*)
Difficulty of breathing (*)
Sore throat (*)

Symptoms	Yes	No
Vomiting (*)
Diarrhea (*)
Skin haemorrhage (*)
Rash (*)

List of vaccines or biologicals used

History of exposure: During the last 14 days, did you (*)

	Yes	No
Visit any poultry farm / living animal market / slaughter house / contact to animal(*)
Care for a sick person of communicables diseases(*)

The data you provide is completely confidential and only serves for the prevention of epidemics, under the management of the Steering Committee for Disease Prevention Covid-19 of Bitexco Joint Stock Company and its attached units. When you press "Submit", you understand and agree with the above statement.