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COVID-19 REGISTRATION
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Name
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Email
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Nationality
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Hotel of Alternative State Quarantine name
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Flight Number
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Which country do you fly from?
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Arrival Date
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Arrival Time
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Do you experience any of the following respiratory conditions in the last 14 days?
Cough
Sore throat
Nasal Congestion
Not smell/Anosmia
Respiratory tachypnea, Shortness of breath, Dyspnea
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Do you have a history of fever detected?
No fever
Body temperature ≥ 37.5°C
Have history of fever
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Have you been confirmed COVID-19 infected?
Never
Yes, I have
When was diagnosed?
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How are they treated?
Treated at home
Admitted in hospital
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What is your medical history?
None of the medical history/Don't have any disease
Dyslipidemia
Coronary artery disease (CAD)
Diabetes
Renal Failure
Hypertension
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Do you smoke?
Yes, I smoke
No, I don't smoke
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Do you drink alcohol?
Yes, I drink
No, I don't drink
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Do you currently taking any medicine?
No, I don't
Yes, I do
Please specify medicine name
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How many hours of sleep do you need?
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Do you need to take sleeping pill?
No, I don't
Yes, I do
Please specify sleeping pill name
Health care coverage / Social security (contracted hospital)
For social security : Would you like us refer you to contracted hospital ?
No
Yes
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The destination after 14 days of quarantine, such as hotel name and etc.
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COVID-19 Screening consent
I agree to do COVID-19 screening test
Please attach file for the COVID-19 test report (Minimum file size 2MB)
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