test register – Cidvid

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Registration form

PLEASE ANSWER THE FOLLOWING QUESTIONS; THIS QUESTIONNAIRE IS IMPORTANT TO DELIVER YOUR TEST RESULT.

Name

Last Name

Date of Birth

Phone Number

E-mail

Gender

Male

Female

Nationality

State

Home Address

Contact with a COVID-19 suspect or confirmed person

Yes

No

Symptoms (only if you present some)

Fever

Cough

Headache

Shortness of breath

Muscle pain

Chest pain

Conjunctivitis

Loss of smell

Loss of taste

Diarrhea

Vomiting

Abdominal pain

Symptoms onset date (only if you present)

Some chronic illness

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Facturación

Atención a clientes

Tel: 33 2002 8697 Extensión 301

Correo: contacto@cidvid.com.mx

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