Khai báo cách ly tại nhà - Khai Báo Y Tế

STATEMENT FOR HEALTH ISOLATION AT HOME

Warning: Declaring false information is a violation of Vietnamese law and may result in criminal prosecution.

If you have made a declare please: Redeclare

Full name*:

Gender*:

Male Female

Nationality*:

Your phone number*:

Passport Number/ID Card:

Year of birth:

Health insurance card number:

Email:

Number quarantine decision*:

Residence*:

Body temperature*:

Quarantine start date*:

End date of isolation*:

Vaccination date:

Covid test date:

Currently isolating by type*:

In the past 14 days, have you experienced at least 1 of the following symptoms: fever, cough, shortness of breath, pneumonia, pain, fatigue??

	Yes	No
Patients with or suspected of having COVID-19*
People from countries with COVID-19*
Symptoms (fever, cough, difficulty breathing, sore throat)*

In the past 14 days have you had symptoms such as cough, fever, sore throat, fatigue, pneumonia, loss of taste and smell?* No Yes

Upload personal photos (face photo, no mask) for face

Tải ảnh lên

Please enter the security code*:

* Hotline support: (0236) 1022 * Electronic declarations can replace paper slip declarations * The data you provide is completely confidential and is for epidemic prevention only