Medical Tourism Participant
Health Declaration Form
Personal Information
Full Name
Gender
Male
Female
Other
Date of Birth
Passport Number
Nationality
Contact Number
Email Address
Travel Information
Arrival Date
Departure Date
Destination Hospital/Clinic
Permanence Address
Medical History
Have you had any of the following conditions? (Select all that apply)
Diabetes
Hypertension
Heart Disease
Asthma
None
Please list any other significant illnesses, allergies, or surgeries
Are you currently taking any medication?
No
Yes
If yes, please list the medications
COVID-19 & Infectious Disease Declaration
Have you experienced any symptoms such as fever, cough, or difficulty breathing in the last 14 days?
No
Yes
Have you been in contact with a confirmed case of COVID-19 or any contagious disease in past 14 days?
No
Yes
Declaration & Consent
I hereby declare that the information provided above is true and correct to the best of my knowledge.
I agree
Date
Signature