MEDICAL DECLARATION FORM IN VIETNAM

MEDICAL DECLARATION FORM

This is important document, your information is vital to allow health

authorities contact you to prevent communicable diseases

Click here to download: MEDICAL DECLARATION FORM

Full name (BLOCK LETTERS): …………………………………………………………………………….

Date of Birth: …………………… Gender: …………….. Nationality: …………………………

Passport number or other legal document: ………………………………………………………………………..

Travel information: Plane £ Ship  £ Automobile £ Other (clarify): …….……………………..

Transportation No.:……………………….…… Seat No.:………………………………………….

Departure date: ……. /……../…………….. Immigation date: ……. /……../……………………………………..

Place of departure (province/country): ……………………….…………………………………..

Place of destination (province/country): ..………….……………………………………………..

In the past 14 days, have you been to any province/city/territory/country? If yes, where?:

Contact information in Viet Nam

Staying address:…………………………………………………………………………………………………..

Tel./Mob.: …………………………………….Email: …………………………………………………

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

Symptoms

Yes

No

Fever

Cough

Difficulty of breathing

Sore throat

[  ]

[  ]

[  ]

[  ]

[  ]

[  ]

[  ]

[  ]

Vomiting

Diarrhea

Rash

Skin haemorrhage

[  ]

[  ]

[  ]

[  ]

[  ]

[  ]

[  ]

[  ]

List of vaccines or biologicals used: ……………………………………………………………………….

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

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

The information I have given is true, correct and complete. I understand failure to answer any question may have serious consequences.

Day:     Month:       Year: 202..   Signature of Passenger/ Crew

GUIDANCE

Passenger uses this part for entry/exit/transit clearance and for protection of your health

Full name (BLOCK LETTERS): …………………………………………………

Province/City/Territory/Country of departure: ………………………………….

VERIFICATION BY
HEALTH QUARANTINE OFFICER

 

  

 

Date     Month     Year 202

For your own heath and that of the community, if you experience any of the above-mentioned symptoms, please contact heath quarantine units at points entry or the nearest healthcare centre or email to Email: kdytqtbrvt@gmail.com or Fax: 0254.3838987

Hotline of province/city of point of entry: 0913.684195 Dr. Pho Đuc Thang

Hotline of the Ministry of Health: …

 

Bài viết cùng chủ đề

You must be logged in to post a comment.
Menu

Tàu cao tốc Côn Đảo Express