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:
<April 2024>
SunMonTueWedThuFriSat
123456
78910111213
14151617181920
21222324252627
282930

Please select the departure date


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