Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Zika Virus Disease Request for Testing

  1. Physician Use Only

  2. Reason for Testing

  3. Travel History

  4. Did Patient Live in a Dengue-Endemic Country:

  5. Reporting Jurisdiction

  6. Demographic Information

  7. Obstetric Information (if applicable)

  8. Pregnant:

  9. Was Fetal Ultrasound done?

  10. Finding of ultrasound:

  11. Vaccination Information

  12. Received Yellow Fever Vaccine:

  13. Received Japanese Encephalitis Vaccine:

  14. Clinical Information (if applicable)

  15. Fever:

  16. Rash:

  17. Type:

  18. Additional Clinical Symptoms:

  19. Specimen Information

  20. Specimen Type:

  21. Leave This Blank:

  22. This field is not part of the form submission.