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:
<November 2024>
SunMonTueWedThuFriSat
12
3456789
10111213141516
17181920212223
24252627282930

Please select the departure date


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