Covid Test Questionnaire
Please fill in all the required fields in order to submit your form. Make sure all the names and information MATCH the passport, this will be checked by the airlines.
Full Name EXACTLY as in passport
*
Name and middle name
Lastname
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Email for results delivery
*
Please double check your email adress
Phone Number
Please enter a valid phone number.
Format: +1 (000) 000-0000.
Gender
*
Male
Female
Passport Number
*
Are you pregnant?
Yes
No
Pregnancy time
Please Select
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
Reason for getting tested
*
Please Select
Travel back to the US or Canada
Suspecting or with symptoms of Covid19
Where are you traveling?
*
Please Select
United States
Canada
Other
US requires Antigen test, CAN requires Pcr test
Home Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
ZIP code
*
your home ZIP code
Do you have US insurance?
*
YES
NO
US insurance name
Flight Date
/
Month
/
Day
Year
Flight date
/
Mes
/
Día
Año
How many people are traveling with you?
*
Please Select
0
1
2
3
4
You can add up to 4 more people
Guest 1
Guest 1 Info
Full Name EXACTLY as in passport
*
Name and middle name
Lastname
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Gender
*
Male
Female
Passport Number
*
Do you have US insurance?
*
YES
NO
US insurance name
Is she pregnant?
Yes
No
Pregnancy time
Please Select
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
Guest 2
Guest 2 info
Full Name EXACTLY as in passport
*
Name and middle name
Lastname
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Gender
*
Male
Female
Passport Number
*
Do you have US insurance?
*
YES
NO
US insurance name
Is she pregnant?
Yes
No
Pregnancy time
Please Select
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
Guest 3
Guest 3 info
Full Name EXACTLY as in passport
*
Name and middle name
Lastname
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Gender
*
Male
Female
Passport Number
*
Do you have US insurance?
*
YES
NO
US insurance name
Is she pregnant?
Yes
No
Pregnancy time
Please Select
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
Guest 4
Guest 4 info
Full Name EXACTLY as in passport
*
Name and middle name
Lastname
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Age
*
Gender
*
Male
Female
Passport Number
*
Do you have US insurance?
*
YES
NO
US insurance name
Is she pregnant?
Yes
No
Pregnancy time
Please Select
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
Section stopper
When did you start with your symptoms?
-
Month
-
Day
Year
Date
What are your symptoms?
Rows
Mark all you have
Fever
Dry cough
Sore throat
Headache
Difficult breathing
Runny nose
Body aches
Chest pain (Pain or pressure in the chest)
Conjunctivitis/redness in the eyes
Vomiting
Diarrhea
Loss of Smell
Loss of taste
Where are you staying?
*
Please Select
Hotel or Resort
Private residence
*
San José del Cabo
Cabo San Lucas
What is the address?
*
Street Address
Name or number of the house
House development
State / Province
Reference to arrive
Hotel or Resort name
Please make sure the resort will allow testing from us.
Room number
Test needed for your destination:
*
ANTIGEN Covid-19 test
PCR Covid-19 test
PCR Test Appointments
*
Antigen Test Appointments
*
Date
-
Month
-
Day
Year
Date
SUBMIT
Should be Empty: