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  • ~ --.------... ------·--

  • --------------------·----- --------·-·- - ------ --------

    DHSS/AHQ 1 Confi rmation Letter

    Ministry of Pub lic Health Alternative Hospital Quarantine

    Patient·s Name: ______________ Passport No~. _________ _

    Nationality: _____ _______ Sex: 0 Male 0 Female

    Flight No.: _____ _____ Dateof Arrival: _______________ _

    Date of Admission: Date of Discharge: ________ _

    Accommodation in Thailand: ____________ ____________ _

    This is to certify that the above pati ent has been accepted for treatment andtor medical procedures under my attendance during the period described below. The conditions to be treated and the procedures are:

    Medical cond itions.'-:-----------------------------

    Planned procedures.'-:-----------------------------

    Treatment period'-:-----------------------------Name of Hospital'-:----------------------------Address: Telephone: Fax:

    Name of Attending Physician.'-:-------------------------Medical license Number'-:---------------------------

    Payment for this medical service is to be paid by: 0 The patient 0 Health InsurancetLife Insurance

    0 The Government of. .............. .... ... ........ .. .. ....... ...... ..... .... ............. .. cName ofthe Payer Agency .......... .. ..... .. ...... .. .......... .. ............... .... .. )

    0 Other Health Plan .. ....... .. .. .. ... ..... .. ..... ..... .... ....... .... . International Health Division

    cSignatureJ .. .. ...... ..... ............. ... . cAuthorized Representative) No. 0712.061 .. .... .. .. ........ .. .1

    · Name .. ..... .. .... .. ........... ........ and Position .. .. .. ...... .. .. .. ...... ............ . Year ... 20 .......... .... .. .. ... : ..

    .Date .. .. .......... .. ............... ............ .................. ......... ..

    Date ( ............... . ..!. . ............... . . . . ./ . . . .. .. ... .... ..... .. ) T ime ........ .. ...... .. ........... ...... ... ... ... .. .. .. ..... .......... . .. . (j Jospiw! .)'eal)

    rSignatureJ .. ......... .. .... ... ...................... ... ....... .. .. ..

    tAuthorized ofi ntem ational Health Division,

    Note: The patient(s) who request for medical treatment in the Alternative· Hospital Quarantine program must pay all actual expense for themselves and their entourage(s) unless the patient(s) is · unable to pay for any reasons, the hospital(s) where the patient and the entourage(s) receive the treatment, shall accept to have a responsibility for all medical expenses occurred without a medical claim from the government agencies.

    Version Las oj 7 August 2020

  • DHSS/AHQ 2

    Affidavit of Support

    This is to certify that individuals listed below are accompanying me during my visit for medical treatment in Thailand. These indiv iduals of not exceed 3 persons in total are my assistants during the course of treatment. They will temporarily stay in Thailand no longer than ......... days. And I will take full financial responsibili ty to their provisions and accommodations.

    (Patients details) Title: Mr. 1 Ms. 1 Mrs. 1 others .... .............. .. ......... ...... .. ..... ....... . Name ...................... .. ................... .. Passport NO .................................. ........ .. Nationality ........... ... ....... .... ...... ......... ....................................... .. ............................ .. .... ..

    I . List of entourages: First Name1Last Name ................. .. ..... ........ ...... .... ..... ..... .. ............ .... .. ........ ..... .

    Sex : D Male D Female Date of Birth ...... . .I ........ .1 .... .. ... (dd!lnm;yyyyJ Passport NO ...... ................... .. ........... ...... .... Nationality ...... .... .... .. .. .... .... ...... .. Relationship ...... ....... ... .... ... ... .. ....... ..... ... ....... .. .... ....... ... .... ... .... .. .... .. .... ... .... .

    2. List of entourages: First Name1Last Name. ~ ... ... .......... .. .................. ....... ................ ........ .... ............ ..

    Sex : D Male D Female Date of Birth ....... .1. .... ... ./ .. .. .. ... (ddllnm;yyyyl Passport NO ............ ... .. .... ... ....... ... .............. Nationality ..... ...... ........ ....... ........ . Relationship ........................................ ... ... ..................... ... .. .. ..... ... .. .. .. ....... ..

    3. List of entourages: First Name1Last Name ................... ... .. .. .............. ... ............... ....... .. ... .... .. ... .. .... ..

    Sex : D Male D Female Date of Birth .. ..... .1 .. ...... ./ ......... (ddllnm;yyyyJ Passport NO ........... ... ... ........ .... .. ... .. .. .... ...... Nationality ... ....... .... ... .............. ... . Relationship ..... ... ... ........... ....... .......... ...... ..... .. ... .... .. ... .. ....... ... .. .... ....... ..... . ..

    . I and my entourages will arrive ........ .. ...... .. .. .. .................................... .. . Airport on

    B Y .................... ...... ................ ............ ............... ..... f..!.i.g!:.! .. ~ o. . ................ ~~ ... ...................... ... .................... .

    I hereby certify that the persons listed above are under my financial responsibility during my visit for medical treatment in Thailand

    I I Signature ...................................... ....... .. ............. .. ........ .. .... ............................ .P..~!~ ..... . ....................................................................................................... ~ ............ ........................... .. ............ .

    •The form needed to be completed and submitted to elective hospital before you arrive. Please

    bring originals to process the immigration at custom control, AirpoJ1, Thailand.

    (J-fusp ira/ .)"eal)

  • To whom it may concern

    This is to ce1tify that (hospital's name) , as a responsible medical hub providing medical treatment of _______ -.>..J(p:::..:a=-=t~ie~n'-"t-=' s'-'n'"'-'a=m=e 2.~---_______ _ passport number __ _:_ _____ , and the entourage(s) Centoura2:e's name) passport number _______ _

    (hospital's name) agrees to be responsible for all medical expenses and treatment whether the patients and the entourage(s) exceed the prescribed medical expenses or if there are any reasons for not being able to respond for the expenses without any reimbursement from any government's agencies.

    Please do not hesitate to contact us regarding any further information.

    Yours sincerely,

    -Signature-

    Name (authorised person) Position _______ _

    -----

  • No Full Name

    .., .., . .. ,..,uov!',•••:n·• t •ro..--t,. •I•·., ~.-... , -,,.,. ...

    Nationalit y

    Summary Form of Alternative Hospital Quarantine's Patients and Follower·s

    Name of Hospital ........................................................................ .

    Date ........................... : ............................................ .

    Please Check I Magnet Name Departure Airport (In Case Passport No. Arrival Date

    Date of Charter Fight) Patient Follower

    DHSS/AHQ 3

    Note Depa•·turc (In case of recei1•ing

    Countl"}' CO£, please sp ecifj')

    Magnet List Magnet 3 Eye/ENT Magnet 10 Retreat/Anti Aging

    Document as the Center for COVID-19 Situation Administration (CCSA) defiucd as follower,

    I. Fit to Fly Health Certificate/Fit to Travel Health Certificate

    Magnet 5 Muscle/Orthopedic/ Skeletal Magnet 10.1 PT

    Magnet 7 [VF Magnet 8 Dental

    Magnet 7.1 Ob_Gyn Magnet 6 NCD/Med/Surg/Ped/Nephro/

    Magnet 9 Sex Reassignment Reproductive organ

    Magnet 9.1 Plastic Surgery/ Beauty Skeletal

    2. Confirmation Letter and Copy of Passport

    3. Affidavit of Support and Copy of Passport (Only for followers)

    4. Bookbank or Statement of Patients for Medical Expense in Thailand

    5. lnsurance covered COVID-19 treatment not less than 100,000 USD

    6. Quarantine Official Letter in Hospital

    (Signalllre) .... . .. . . . ... ... . . .... .• . ... . . . . . ... . . ... ..

    (Authorized oflntcmational Health Division,

    Depnrtmcnt of Health Sen• icc Support)

  • DHSS/AHQ 4

    Summary Form of Vehicles for Pa tients

    Name of Hospital ................ ........................... ..... .......... .... ..... ... .. .

    Date .... · ...... ...... ... ... ...... .................... ... .

    No Vehicle Registration No. Pick up the Pick up the

    Name of Driver Name of C rew Note patient No. follwer No. (if any)

    Name of COVID Commander

    (Signature) .... ... ............... ...... .. ................. ... ......... ....... . ( ............ ... ..... .. ......... ... ....... )

    Position ............... ...... ......................... ... . Tel. ......................................................... .

    ( (-{u.,p i rrt l ,\'cal)

    I

  • No.0712.07/ Ministry of Public Health (Thailand) Nonthaburi, Thailand 11000

    Date .............. Month ..... ............ Year.. ......... ..

    This letter is to certify that (Name- Surname) .. . ...................... .... .. ........... ..

    Identification No./Passport No .... ... ................................................ ....... ............... . age .................... years, Nationality .......................... ... ... . Address: House No .... ......... ........... ..... . .. Village No . .. .... .... ...... Lane ........ .... ...................... .... .... .... ... Road ........ .... .............. ................. .. .. . Sub-area/Sub-district............ .... .... ..... ..... .... .... Area/District .. . .. ......... ............. ..... .... ................... .. Province ..... ........ ... ... ............ .. ...... is ordered by the communicable disease control officer to be n isolated [] quarantined n controlled for health observation at ... .. .. ..... ....... . ..... ... . ...... .

    since day ... ....... month .. .... ... .... ......... ... year ..... ... ...... , until day ..... .. month ........ ......... ..... ... .. year .... .... ....... total duration ... . ......... . ... .... ..... days. Now, the quarantine or observation period has been completed according to the time specified by the communicable disease control officer. Therefore, the said person is able to continue his or her career, participate in activities or perfonn normal tasks .

    ( ...... , ... ···· · ... ............ ...... .. .. ........... ... ................ ... . ) (Authorized by the Communicable Disease Control Officer

    o( Provincial Health Office, except Bangkok authorized by Deputy- Permanent Secretary, or Director~General of

    Department of Health Service Support)

    Please note: 1. This letter is provided for identification purpose to the employer/relevant parties that the said person has complied with the order of the communicable disease control officer by staying at the specified place until the end of the quarantine period only.

    2. This letter cannot be used to confirm that the said person is not COVID 19 infected or has no risk of infection or used for any other purpose after the said person completed his or her quarantine or observation period under the orders of the communicable disease control officer. ·

    Note : Case hy Cw;e orrzv

  • 11~£'l~b~8\9l't.h~nB'Um-a

  • -------- ~--·-------

    Fit For Travel Medical Certificate ~fj~fiYEfY1

    Name t!i.:6

    HN . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date 8 jtJl ...... .. ...... .. ........ .. .............. ............... ... .... .

    Birth Date t±l~ 8 W3 .. . . .. .. . . .. . . . . . . .. . . .. . . . Age ~§'i ..... .... ... .. ..... ....... .. ... ........ .... ..... ......... .

    Room ffif-5 ..... .... .. . . .. .. .. . . .. . .. .. .. .. . . .. . . .. .. Sex 't~jjlj ..................................... . ........... ..

    Physician~~ ........ . .. . . .. .. ... ..... ..... .... · ·. · . .. . ·· · · ·· · · · · · ···· · · · ·· · ··· · · · · · · ··· · · · · · · · · ··· · ·· · · · · ··· · ·· ·· ·

    DateofExamination i*1:&8JtJl .... ... .... ............. ........ ... ....... .. . Time a;JfBJ ............ ... ........ ... . .

    To Whom It May Concern: fllirJE ~

    This is certify that above name 's patient has examined and treated at our hospital an: :\3:iiE a)3 ~i.;S 8{] ·*'~ B.f:Eftfi'J ~~~j~~;f"B:~ .fiiiTi1Y :

    0 Out patient n ;~ D in-patient on/during fillJG .. ........................................................ .. Diagnosis iti3YT: ................................... · .. ... ............ . · · .. · ........ · .. · .. · .. · .... · · · .. · .. · .... · .. · · .. · .. ..

    Travel Recommendation and Assessment (Please tick in the box): Jn~Vfi:HI~{¥.!:3·~'1

  • -----

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