Health Declaration Page – Health Declaration Form

Health Declaration Form

"*" indicates required fields

Arrival Date*

Full Name*

Gender*

Male

Female

Nationality*

Passport Number*

Email*

Enter Email Confirm Email

Date of birth*

Phone Number*

Flight/Vessel/Vehicle Number*

Seat Number

Country of Residence*

Country of First Departure*

Transit Airport

Transit Country

Countries Visited in the last 21 days

Country

Destination in Nigeria (For the next 21 days)

Address*

Phone*

Emergency Contact in Nigeria or Next of Kin

Full Name*

Phone*

In The Last 21 Days Did You Have any of the Following? (Please tick Yes Or No)

Fever*

Yes

Cough*

Yes

Sneezing*

Yes

Generally feeling unwell*

Yes

Rashes*

Yes

Difficulty breathing*

Yes

Jaundice*

Yes

Nose/Ear Bleeding*

Yes

Other Symptoms*

Yes

Other

In the Last 21 days Have you Had Contact with anyone who was not feeling well with the following? (Please tick Yes Or No)