Long Bien Golf Course

Booking now MEDICAL DECLARATION FORM

Tan Son Nhat Golf Course

MEDICAL DECLARATION FORM (For customers)

Full name (BLOCK LETTERS) (*):

Telephone number (*):

Living and working in (*): Ha Noi Other provinces

Covid 19 Vaccine injection (*): 01 shot 02 shots Not yet injected

Result of test for Covid 19 within 72 hours (*): Negative Positive Not yet tested

Date of Birth:

Gender:

Nationality:

Booking ID :

	Yes	No
Contact with people directly caring for people with Covid 19 (*)
Contact with people from abroad (where there is the Covid epidemic) returning (*)
* Contact with an infected or suspected person with Covid 19 (F0, F1, F2, F3) (*)
Contact with suspected person with fever,cough, shortness of breath, pneumonia (*)
Living in or going to or in contact with people in a high-risk area (*)

I hereby declare that the above information is true and understand that providing false information may lead to serious consequences.