GOODMED

At GoodMed we care about all the people, that is why we require all patients to submit personal data exactly as issued on their ID document, which must be valid. It is of utmost importance that patients describe all of their symptoms truly, accordingly to their health status.

The lab results will include all the information shared on this form and no one at the GoodMed team will be able to modify any data on this form.

Due to national regulations, all the information shared by you on this form will be checked by the a Ministry of Health of Costa Rica. It is vital that the contact information you provide, such as physical address, phone number, and e-mail address allows the clinical lab or any health national authority to reach you at any time, if needed.

We at GoodMed are obliged to share with the Ministry of Health of Costa Rica all the lab results for COVID-19 tests performed at our facilities, for they are part of the epidemiological surveillance program on the current SARS-CoV-2 pandemic.

*  I have read the conditions and accept personal responsibility for providing correct information.

* Indicates required field

Select the test for SARS-CoV2 you need
*
Demographic data
ID type
*
ID NUMBER
*
Name
*
Last name(1)
*
Last name(2)
Gender
*
Nationality
*
Date of Birth (month/day/year(4))
*
Phone (+ country number)
*
Email address
*
Type again email address
*
 Patient is a minor?
For minors (*) or patients with a legal tutor:
Type
ID type
ID
Name
Last name(1)
Last name(2)
 This test is for travel reasons?
If you are traveling, select date and time
Time
Destination
Geographic location data
Province
*
Municipality
*
District
*
Neighborhood
*
Exact address
*
 Work in Costa Rica?
Wokplace
Name of your workplace
Position
Province
Municipality
District
Neighborhood
Exact adress
Have you had symptoms of covid or in contact with a case?
*
Clinical Data
Date of Symptoms Start
 Pregnancy
Pregnancy weeks
 Hospitalized
 Deceased
 Autopsy
 Deceased at hospital
Symptoms
 Contact of someone who has tested positive for COVID-19
 Fever
 Recent or aggravated respiratory distress
 Recent dry cough
 Recent sore throat
 Recent fatigue
 Recent headache
 Recent muscle pain
 Recent loss of sense of smell
 Recent diarrhea
 Recent nasal congestión/runny nose
 Recent loss of sense of taste
 Disorientation/Irritability
 Confusion
 Chest Pain
 Abdominal Pain
 Joint Pain
Other Symptoms
Signs
 Pharyngeal exudate
 Conjunctival injection
 Coma
 Dyspnea/Tachypnea
 Abnormal Breath Sounds and Auscultation
 Abnormal X-Ray Findings
Clinical History
 Have you been abroad in the last month?
 Older than 60 years old
 Diabetic or high blood sugar levels
 Hypertensive or High Blood Pressure
 Cardiopathy
 Lung disease
 immunosuppressed
 Asthma
 Chronic obstructive pulmonary disease (COPD)
 Morbid obesity
 Cancer
 HIV
 Puerperium
 Pregnancy
 Liver disease
 Neurological disorders