FORM
COVID-19 TEST REQUEST

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Name and last name (passport)
Passport number

Birthdate
Month: Day: Year:



Age

Address in Costa Rica
Reason for the test
Nacionality
Phone number
E-mail address

Secundary E-mail (Optional)

Language of the result
PDF file in?




Select the type of test you need
PCR or Antigen?




Flight Information
¡Important to know when is the right time to test!
Departure date:
<January 2025>
SunMonTueWedThuFriSat
1234
567891011
12131415161718
19202122232425
262728293031

Please select the departure date


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