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)?

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

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

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

GUIDANCE