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 Test to perform PCR real time Antigen test Saliva antigen Laboratory studies 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 Enviar Submitted successfully