Covid-19 Health Declaration Form

Thank you for your cooperation and understanding in filling out this Covid-19 Health Declaration Form prior to your arrival at Lua Cheia.

Due to the ongoing and rapidly changing situation with the novel-coronavirus (COVID-19), we are requiring all visitors to Lua Cheia to fill-out the self-declaration form below. We will make a decision on access to the villa based on the answers provided.
Each visitor must complete and submit this form at least 48 hours prior to arrival.

The health and wellbeing of our guests, staff and village is our first priority, therefore Lua Cheia reserves the right to deny entry to our compound to anyone who exhibits symptoms of Covid-19 or who has been in contact with anyone who has tested positive for the virus.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Date of Arrival at Lua Cheia

MM

DD

YYYY

Duration of Stay (in days)

Do you have any of the following flu-like symptoms?

Fever (37.5 degrees or higher)

Cough

Breathlessness

Loss of smell and/or taste

None

In the past 14 days, have you been exposed to anyone who has tested positive or who has exhibited symptoms of Covid-19?

Yes

No

Have you traveled to a different city/country during the last 14 days

Yes

No

If you answered yes to the above, please list the cities or countries you have visited

By signing this self-declaration form, I confirm that I have not tested positive for Covid-19 in the last 14 days or been required to be in a quarantine during the last 7 days. I confirm that the above information is an accurate representation of my health and symptoms. I understand that failure to answer any question or giving a false answer will result in a refusal of entrance the Lua Cheia compound and a forfeited payment.

Signature

Date

MM

DD

YYYY

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