Form Pernyataan Kesehatan

(Health Declaration Form)
Sebelum melanjutkan reservasi, silahkan isi form pernyataan berikut. Lenere Business Suite akan menganalisa kondisi riwayat kesehatan Anda yang berkaitan dengan COVID-19 dalam 14 hari terakhir.
Before continuing your reservation, please fill in the following statement form. Lenere Business Suite will analyze the condition of your medical history related to COVID-19 in the last 14 days.
Surel*
Email
Jenis Keperluan*
Type of Purpose

Form Pernyataan Kesehatan

(Health Declaration Form)
Nama Lengkap*
Full Name
Alamat*
Address
No. Telepon*
Phone Number
Jenis Kelamin*
Gender
Lokasi Lenere Business Suite*
Lenere Business Suite Location

Form Pernyataan Kesehatan

(Health Declaration Form)
Dalam 14 hari terakhir, apakah anda pernah mengalami hal ??? hal berikut:*
In the past 14 days, have you experienced any of the following:
Apakah Anda dalam keadaan sehat?
Are you in good health?
Pernah kontak langsung dengan Pasien COVID-19?
Have you been in direct contact with a COVID-19 patient?
Apakah pernah melakukan perjalanan ke luar kota / internasional? (wilayah yang terjangkit / zona merah
Have you ever traveled outside the city / international? (affected area / red zone)
Apakah pernah mengikuti kegiatan yang melibatkan orang banyak?
Have you ever participated in an activity that involved a lot of people?
Apakah memiliki riwayat kontak erat dengan orang yang dinyatakan ODP,PDP atau konfirm COVID-19 (berjabat tangan berbicara, berada dalam satu ruangan / satu rumah)?
Do you have a history of close contact with people who are declared ODP, PDP or confirm COVID-19 (shaking hands talking, being in one room / one house)?
Apakah pernah mengalami demam / batuk / pilek / sakit tenggorokan / sesak dalam 14 hari terakhir?
Have you ever experienced a fever / cough / runny nose / sore throat / tightness in the last 14 days?
Apakah Anda pernah terkena COVID-19?
Have you ever had COVID-19?

Form Pernyataan Kesehatan

(Health Declaration Form)
Declaration
Dengan mengisi dan menyetujui form ini, Anda menyatakan dalam keadaan sehat dan apabila dikemudian hari terbukti memalsukan kebenaran pernyataan riwayat yang berkaitan dengan COVID-19 maka Anda bersedia menerima sanksi sesuai ketentuan peraturan perundang-undangan serta membebaskan Lenere Business Suite terkait hal tersebut.*
By filling out and agreeing to this form, you declare that you are in good health and if in the future it is proven to falsify the truth of the historical statement relating to COVID-19, then you are willing to accept sanctions in accordance with statutory provisions and release Lenere Business Suite related to it.