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Brazil Health Declaration

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HEALTH DECLARATION FORM

✴ Please refer to the exclusions and conditions relating to the Medical and Cancellation sections of this insurance which apply to you, all travelling companions and anyone upon whose state of health your decision to cancel or curtail your trip would depend.

✴ If you think any of these exclusions or conditions apply, you must complete both sides of this form and send it to us within 14 days of receiving the insurance at the following address

Fogg Travel Insurance Services Limited, Crow Hill Drive, Mansfield, Notts. NG19 7AE (Tel : 01623 635958)
or by Fax on 01623 632861

✴ It is a condition of this insurance that you advise us of all material facts, which might influence us in the issue of this insurance to you.

✴ If necessary, please continue on a separate sheet.

Your Insurance (please tick as appropriate)

Name of insurance :

Date of Issue (if already issued) :

Is this an Annual Policy? YES NO

To include Winter Sports? YES NO

Have you been declined travel cover elsewhere or had special Terms imposed? YES NO

If YES, please give details

Your Travel Arrangements

Travel Dates : From : To :

Countries to be visited :

Number of persons to be insured?

Details of any planned high risk activities, e.g. skiing, scuba diving, white water rafting etc:

Are you permanently resident in the UK : YES NO

Date of Birth :

Your Details

Name :

Address :

Tel (inc code) :

Fax (inc code) :

E-mail address:

Post Code :

NB. We may use the above in order to communicate with you regarding confidential medical information

Part A - applies to those NOT travelling with you or those with whom you intend to stay.

Part B - (overleaf) applies to YOU and YOUR travelling companions. Where necessary a separate form should be completed by each person

Part A: Applies only to those not travelling with you (e.g. relative), or those with whom you intend to stay and upon whose state of health your decision to cancel or curtail your trip would depend.

If the person concerned has received a terminal prognosis no cover will be provided by the Insurer in respect of Cancellation or Curtailment of the Journey.

Name & Relationship Age/DOB Specify all medical conditions Date of onset Details of medication and dosages Any treatment or hospital admission in the past 12 months How often are check-ups required

Is this person or any other person awaiting hospital treatment or investigation? YES NO If so, please give brief details :

If there are no medical conditions applying to anyone not travelling with you or with whom you intend to stay, write NO in this box :

Part B : Applies only to YOU and YOUR travelling companions

B - SECTION 1 – Have YOU or any of YOUR travelling companions had a cancerous, cardio-vascular, cerebro-vascular, renal, psychiatric or mental condition?

YES NO If you ticked YES, please complete the section below:

NAME(S) AGE/DOB CONDITION(S) DETAILS OF MEDICATION AND DOSAGES DATE OF ONSET ADVISE HOW OFTEN CHECK-UPS ARE REQUIRED

B - SECTION 2 – Have YOU or any of YOUR travelling companions had any other medical condition which is under the supervision of a hospital or a consultant or doctor or has required any hospital admission or treatment in the last twelve months

YES NO If you ticked YES, please complete the section below.

NAME(S) AGE/DOB CONDITION(S) DETAILS OF MEDICATION AND DOSAGES DATE OF ONSET ADVISE HOW OFTEN CHECK-UPS ARE REQUIRED

B - SECTION 3 – Have YOU or any of YOUR travelling companions been taking continuous medication and have had any change in the medication or increase in dosage in the last twelve months resulting from a deterioration in the condition being treated?

YES NO If you ticked YES, please complete the section below.

NAME :

DETAILS :

NAME :

DETAILS :

B - SECTION 4 – Do YOU or any of YOUR travelling companions have any medical condition for which you are on a hospital waiting list or awaiting the results of test or investigations?

YES NO If you ticked YES, please complete the section below.

NAME :

DETAILS :

NAME :

DETAILS :

DECLARATION

I declare that all the information provided on this form and on any attachments is truthful to the best of my knowledge and belief and that no information has been withheld which may influence the insurer in his assessment of this risk. Furthermore, I declare that :

• Neither I nor any of my travelling companions will travel against the advice of a medical doctor

• Neither I nor any of my travelling companions have received a terminal prognosis

• If pregnant, the expected date of delivery is more than 8 weeks before the booked date of return home of myself or my travelling companions

Signed

Print Name

Date

Agent Stamp :

Contact Name :

Fax No :

Fogg Travel Insurance Services Limited is authorised and regulated by the Financial Services Authority.
Our FSA Register reference is 307304.This can be checked at www.fsa.gov.uk/register

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What the Brazil Health Declaration Is and when it’s used

The Brazil Health Declaration is a traveler-facing form used to report recent health status, recent exposures, vaccination information, and contact details for persons entering or re-entering Brazil. It is intended to assist public health authorities with symptom screening, contact tracing, and risk assessment at ports of entry. Versions may be required by airlines, consular offices, or Brazilian border authorities and can be submitted electronically or on paper depending on the carrier and destination entry rules.

Why completing a clear health declaration matters

A complete Brazil Health Declaration helps public health screening and may be required for boarding or entry. For U.S. senders and signers, electronic completion and signatures typically meet legal requirements under the ESIGN Act (15 U.S.C. ch. 96) and UETA when applicable.

Why completing a clear health declaration matters

Who fills and processes the Brazil Health Declaration

The form is completed by travelers and processed by carriers and public health or consular staff prior to or at arrival.

  • International travelers and short-term visitors completing entry screening for Brazil
  • Airline staff and ground agents who verify documentation during check-in and boarding
  • Consular and public health officials handling contact tracing or quarantine logistics

Completing the form accurately streamlines screening and reduces the chance of travel delays or additional health checks.

Typical signers and administrative users

Traveler

An individual entering Brazil who provides personal identification, recent travel itinerary, health symptoms, and vaccination status. The traveler must ensure entries match passport data and sign to attest to accuracy under possible legal or public health consequences.

Public Official

A carrier representative, consular officer, or public health official who reviews submitted declarations, verifies identity where required, and uses the data for boarding decisions, quarantine determinations, or contact tracing under applicable health law.

Essential fields typically required on the form

Full legal name: As shown on passport
Date of birth: MM/DD/YYYY
Passport number: Passport or travel ID
Contact information: Phone and email
Health status: Recent symptoms checklist
Vaccination status: Vaccine type and dates

Immediate risks from incorrect or missing information

Denied boarding: Possible
Entry refusal: Possible
Fines or citations: Possible
Quarantine orders: Possible
Contact tracing delays: Likely
Insurance claim impact: Possible

Common mistakes people make when completing the form

  • Entering names or passport numbers that do not exactly match government ID, which can prevent boarding or slow processing.
  • Using abbreviated state names or inconsistent date formats; this causes validation failures on airline or government portals.
  • Submitting an outdated vaccination record or failing to include booster or recent test results required by the carrier.
  • Assuming a previously submitted form transfers between carriers; many airlines require a fresh declaration per itinerary.

Step-by-step: complete the Brazil Health Declaration

Follow these straightforward steps to complete and submit a compliant health declaration before travel.

  • 01
    Collect documents: Passport, vaccination proof, contact details
  • 02
    Enter personal data: Type name, DOB, passport exactly
  • 03
    Answer health questions: Select recent symptoms and exposures
  • 04
    Sign and submit: Provide signature and confirm submission

Where and how declarations are submitted

Submission routes depend on the airline and port of entry; use the route required by your carrier or consulate.

  • Airline portal: Submit via carrier website or mobile app prior to check-in
  • Brazilian health authority: Submit to any required national portal when specified
  • Consulate or embassy: Used for certain visa or pre-clearance processes
  • At border control: Present printed or electronic confirmation on arrival if requested

How to save and exchange signed declarations

Signed declarations should be stored in common formats and shared with carriers or officials as required; keep a copy for recordkeeping.

PDF copy

Download a locked PDF with visible signature block and audit metadata to present at the gate or immigration checkpoint; PDFs are the preferred archival format.

Printable record

Keep a printed copy where permitted; physical copies are still accepted by many carriers and helpful if mobile access fails during travel.

Electronic confirmation

Keep the confirmation email or SMS received after submission as immediate proof of filing when requested by airline staff or border agents.

Data export

If managing group travel, export form responses to CSV or Excel for contact tracing or internal recordkeeping consistent with privacy obligations.

Key elements of a professional Brazil Health Declaration

A complete professional declaration balances clarity, data minimization, and attestations to accuracy; these components help officials act quickly and consistently.

Identification

Full name, date of birth, passport number and nationality for identity verification at entry.

Contact details

Phone number and email for follow-up contact or public health notification.

Travel itinerary

Recent and planned travel segments to assist contact tracing if exposure is detected.

Symptom checklist

Standardized questions about fever, cough, shortness of breath, and other reportable symptoms.

Vaccination or test status

Vaccine type, dates, or recent test result details as required by regulations or carrier policy.

Attestation and signature

Clear signer statement confirming accuracy plus signature and date to establish responsibility.

How to update or amend a submitted declaration

If your health status or travel plans change, follow these steps to correct the record quickly.

01

Identify need:

Determine which fields require change
02

Contact issuer:

Notify airline or portal support
03

Submit amendment:

Complete a new declaration or amendment form
04

Sign again:

Provide fresh signature with updated date
05

Retain copies:

Save old and new versions for records
06

Notify contacts:

Inform travel companions and officials as needed

Technical notes for electronic submission and eSignatures

Ensure the chosen platform meets privacy and authentication requirements for the traveler population and the receiving authority.

  • File formats: PDF, DOCX accepted
  • Authentication: Email, SMS code, or stronger verification
  • Integrations: Supports CRM and cloud storage integrations

Configure an online declaration workflow

Key workflow settings help ensure accurate collection and secure submission of health declarations.

Field Configuration
Signature Field Enable required signature; timestamp included
Authentication Email link or SMS verification
Conditional Fields Show symptom details only if 'Yes' selected
Audit Trail Capture IP, timestamp, and action log

Representative eSignature vendor pricing and feature overview

Comparison of starting prices and core capabilities across common eSignature vendors; signNow is listed first per standardized pricing references.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial No No No No
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real-world use examples for the Brazil Health Declaration

These examples illustrate common, practical scenarios where a completed declaration is required and how it is used by receiving parties.

Traveler Screening

A family fills the form before check-in

  • carrier verifies vaccination dates
  • the completed declaration expedites boarding and reduces manual health checks at the gate.

Consular Review

A student submits the form with visa materials

  • consulate checks recent symptoms and travel history
  • accurate answers prevent processing delays and additional interviews.

Practical tips for accurate and efficient completion

Follow these practical best practices to reduce errors and avoid processing delays when completing the declaration.

Use exact ID details and consistent formats
Enter names and passport numbers exactly as printed. Use MM/DD/YYYY for dates and include country codes on phone numbers to ensure reliable identity verification.
Upload verifiable supporting documents
Attach vaccination cards or lab results as requested. Scans or photos should be legible; poor images lead to manual follow-up or rejection.
Complete the form before arrival
Submit the declaration via the airline or required portal before check-in to avoid delays and last-minute rework at the gate.
Retain proof of submission
Keep the confirmation email or signed PDF for the trip. It is the primary proof accepted by carriers and remains helpful if questions arise later.

Timing considerations and typical submission windows

Different carriers and authorities set submission windows; confirm the required timing for your itinerary ahead of travel.

Before check-in:

Submit as required by airline policy before online or in-person check-in

Pre-departure:

Some carriers ask for submission within 24–72 hours before departure

On arrival:

Bring printed or electronic proof if asked at border control

After symptom onset:

Report changes immediately to the carrier and health authorities

Recordkeeping:

Retain records for organization-defined retention periods

FAQs and troubleshooting for common submission issues

Answers to frequent questions about e-signing, notarization, and data handling when you prepare a Brazil Health Declaration.


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