* Indicates required field
Dear patient:
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.
Are you a part of a business agreement? *
Are you?
Select the test for SARS-CoV2 you need: *
* The antigen test can be performed in people who need the test as an administrative procedure to travel to a specific country and in the general population ASYMTOMATIC. People with sympoms should request the RT-PCR test.
If you received COVID-19 vaccination, please indicate the following:
Vaccine brand
Number of doses
Date of last dose
If you are traveling, select date and time Time: Destination:
If you are having a surgery, select date and time Time:
If you have had a previous COVID-19 diagnosis, select the date:
ID type: * ID: *
Demographic data
First Name: * Last Name (1): * Last Name (2):
Gender: *
Nationality: *
Phone number (example: +506123456789): * Date of Birth (month/day/year(4)): *
Email address: *
Type again email address: *
For minors (*) or patients with a legal tutor
Type: ID type: ID:
First Name: Last Name (1): Last Name (2):
Geographic location data
Province: * Municipality: * District: *
Neighborhood: *
Exact address : *
Do you work in Costa Rica?: *
Clinical Data
Date of Symptoms Start:  Pregnancy Weeks:  Hospitalized
 Deceased  Autopsy  Deceased at hospital  

 Contact of someone who has tested positive for COVID-19 Recent dry cough Recent sore throat
 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 Hinchazón de la cara y/o garganta
 Latido cardíaco rápido Sarpullido severo en todo el cuerpo Mareos y debilidad
 Dolor en el lugar de la inyección Escalofrios Hinchazón en la zona de la inyección
 Enrojecimiento del lugar de la inyección Náuseas Malestar
 Ganglios linfáticos inflamados Recent or aggravated respiratory distress Recent fatigue
 Recent headache Recent muscle pain Joint Pain
Other Symptoms:

 Pharyngeal exudate Conjunctival injection
 Coma Dyspnea/Tachypnea
 Abnormal Breath Sounds and Auscultation Abnormal X-Ray Findings

Clinical History
 Alergia Fiebre Transtorno hemorrágico
 Periodo de lactancia ¿Ha recibido otra vacuna para COVID-19? 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