• Have a fever, dry cough or/and breathing difficulty?
  
  Yes
  No
• Do you have uncontrolled heart, lung or kidney disease, or diabetes?
  
  Yes
  No
• Do you have flu-like symptoms such as upset stomach, headache or fatigue?
  
  Yes
  No
• Have you tested positive for Covid-19?
  
  Yes
  No
• Had any contact with someone who has tested positive for Covid-19?
  
  Yes
  No
• Have been in a large group or travelled to regions affected by Covid-19 within the last 14 days?
  
  Yes
  No
• Have you travelled to India / Brazil / South Africa or been in contact with someone who has travelled to India / Brazil / South Africa 14 days prior to arrival?
  
  Yes
  No

Please advise name of the countries you have visited in the past 14 days prior arriving to Bali/Jakarta (if any):

Country Name

  I hereby declare that all information I have stated above is true and understand that the hotel reserves the rights to refuse entry.