In the past 14 days, which country / territory have you traveled to (may travel across multiple countries):

Personal Information:

Name:

Phone number

Email:

In the past 14 days, have you noticed any of the following signs of fever, cough, shortness of breath, pneumonia, sore throat, fatigue:

During the past 14 days, you were:

In contact with sick or suspected person, infected with COVID-19?

Get back from countries with COVID-19 disease?

In contact with people from countries with COVID-19 disease?

Have you been vaccinated yet?

If you have recovered from covid-19, please download the certificate of completion of isolation and recovery from the government agency attached below.

Upload vaccination certificate:

Language (ngôn ngữ):

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