International Travel Health Declaration Form
Personal Information
Full Name
Passport Number
Nationality
Date of Birth
Email Address
Phone Number
Travel Information
Flight Number
Departure Country
Arrival Country
Date of Arrival
Address Abroad
Health Information
Have you experienced any of the following symptoms in the last 14 days? (check all that apply)
Fever
Cough
Shortness of Breath
Sore Throat
None
Have you been in contact with a confirmed case of infectious disease in the last 14 days?
Yes
No
Are you fully vaccinated against COVID-19?
Yes
No
Countries visited in the last 21 days
Declaration
I declare that the information given above is true and correct to the best of my knowledge.
Date
Signature