The information you provide on this form should contain the exact same personal data as on your current valid identification document. It is also very important to accurately describe the symptoms based on your health status.

We recommend you meticulously check the personal data you’ve entered, such as: full name, date of birth, and identification document number

The results will be reported with the information you provide and the clinical laboratory will not be responsible for changing data that differs from the data provided on this form.

Your contact information, such as exact address, telephone number, and email address, are also essential so that the clinical laboratory and the Costa Rican Ministry of Health authorities can locate you if necessary, since as part of the COVID-19 (SARS-CoV2) epidemiological control the laboratory is required to notify the Ministry of Health of the results.

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

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Company name *
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
Province
*
Municipality
*
District
*
Neighborhood
*
Exact address or HOTEL name
*
 Work in Costa Rica?
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