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泰国 BNH 医院
The new strain Coronavirus, 2012 or CoVs No. PI-ICD-007.2
Home Quarantine No. PI-ICD-008.2
You will receive Covid-19 instructions again via e-mail. Please fill your information below.
COVID-19 Testing documents
Patient Under Investigation PUI
Are you experiencing the following respiratory conditions with Signs and Symptoms
No Signs and symptoms
Loss of taste
Anosmia ( No sense of smell )
Tachypnea, ( Shortness of breath ) , Dyspnea
History of fever at home
History of fever at hospital < 37.4
History during 14 days before screening
No history of travel abroad
Departure to/from or stay at pandemic COVID-19 high risk areas
Work to any authorized ASQ practitioner
Work 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 ?
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.
What's your relationship with the patient/s?
Patient's signature / Guardian's signature
If you are human, leave this field blank.
泰国 BNH 医院
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