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Date of birth*
What is your occupation*
Line or WhatsApp ID
Passport Expiry date*
Can we know if you arrival date is confirmed
(ie. you have gotten CoE and flights books) or
is it tentative ? *
Which Thai Embassy did you receive your CoE from
(or about to request for a CoE) ?*
Arrival flight / Time *
Card holder name*
Type of card*
Expire date (MM/YY)*
Which provice or town do you plan to go
after completing the State Quarantine ?*
Special notes/ requirements
Your address in Thailand after finishing your quarantine
Please check to indicate if you have ever had the following conditions*
Others hospitaliztions *
Have you ever had a blood transfusion ? *
Allergies to medications
Allergies to food
(Ex.Vegetarian and Vegans, Halal, No beef, etc.)
What is the name and address of your health insurance company ?
Include street number, city, state and ZIP
Note to hotel (Anything you wish to let us know)