PLC Form

FLIGHT INFORMATION:
Airline name Flight number Seat number Date of arrival
AVIANCA AV92 2022-02-11

PERSONAL INFORMATION:
Last (Family) Name First (Given) Name DATE OF BIRTH Your Sex
ROMERO CARLOS 1998-03-12 MALE

CONTACT INFORMATION: (where you can be reached if needed)

Street/ Hotel Phone number
SAN MARCO HOTEL & CASINO +57 320 4296723

Email address: carlosro1998@gmail.com

EMERGENCY CONTACT:
Name Phone number
LIDA SUSANA MARTINEZ +57 320 3451358

HEALTH INFORMATION:
HAVE YOU TRAVELED FOR THE LAST 14 DAYS? NO
HAVE YOU BEEN IN CONTACT WITH A CONFIRMED CASE OF COVID-19? NO

I HAVE THE FOLLOWING COVID-19 SYMPTOMS:

COUGH NO
SNEEZING NO
FEVER/CHILLS NO
LOST OF TASTE OR SMELL NO
SORE THROAT NO
CONGESTED AND OR RUNNY NOSE NO
HEADACHE NO
SHORTNESS OF BREATH (DYSPNEA) NO

PCR TEST:
Date Type Result
2022-02-10 THROAT AND NASAL SWAB NEGATIVE

GROUP ID: LGZHN

INSURANCE INFORMATION:
COUNTRY OF RESIDENT CO
EXEMPTED YES
REASON NOT_YET_APPLICABLE

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