COVID-19 Testing documents

Are you experiencing the following respiratory conditions with Signs and Symptoms *

History during 14 days before screening *

No history of travel abroad

Departure to/from or stay at pandemic COVID-19 high risk areas

Connected to any authorized ASQ practitioner

Visited or indulged with tourist , crowded areas or contact with many people

Closed contact with confirmed corona virus 2019 patients or confirmed case's secretion

Stayed/visited in communities or areas with many people such as ( department store, hospital, public transport, Gambling den, Karaoke room, Pub, Boxing stadium) where found case COVID19 confirmed within 1 month.

List of Countries you visited before arriving in Thailand

Date of Arrival in Thailand

What's the name of the hotel you stayed in and name of the authorized health care provider during your ASQ days??

What is your job occupation/s in your Country and where it is located?

What is your relationship with confirmed case's Covid-19 patient/s ?

Please specify the complete Name/Address/location of the place last visited

All information's given and stated above is reliable and true.

I'am : *

Patient

Patient's guardian

What's your relationship with the patient/s?

Patient's signature / Guardian's signature *

Clear

Covid-19 instructions

Patient Under Investigation PUI

Covid-19 instructions

Patient Under Investigation PUI

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