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Covid Test Form | Formulario Para Prueba Covid
* Please complete all the information as it is required by the Ministry of Health.| *Por favor complete toda la información ya que es requerida por el Ministerio de Salud.
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* Indicates required question
Email
*
Your email
First Name | Nombre
*
Your answer
Middle Name | Segundo Nombre
Your answer
First surname | Apellido
*
Your answer
Second surname | Segundo Apellido
Your answer
ID Type | Tipo de Identificación
*
ID | Cédula Física
DIMEX
Passport | Pasaporte
Required
ID Number | Número de Identificación
*
don't add hyphens (-) | no agregar guiones (-)
Your answer
Phone number
*
Your answer
Date of Birth | Fecha de Nacimiento
*
Si la persona es menor de edad, por favor rellene los datos del Tutor
MM
/
DD
/
YYYY
Nationality | Nacionalidad
*
Your answer
Address in Costa Rica | Dirección detallada
Hotel, condo, airbnb, etc
Your answer
Do you have symptoms related to COVID? | ¿Presenta síntomas relacionados con el COVID?
Yes
No
Destination country | Pais de Destino
*
Your answer
Travel date | Día del viaje
*
MM
/
DD
/
YYYY
TUTOR INFORMATION | DATOS DEL TUTOR
Fill in only if the patient is a minor | Rellenar solo si el paciente es menor de edad
Tutor's full name | Nombre Completo del tutor
Fill in only if the patient is a minor | Rellenar solo si el paciente es menor de edad
Your answer
Tutor ID or Passport number | Número de Identificación o pasaporte del tutor
Fill in only if the patient is a minor | Rellenar solo si el paciente es menor de edad
Your answer
A copy of your responses will be emailed to the address you provided.
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