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Zika Virus Disease Request for Testing

  1. Reason for Testing

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

  3. Pregnant:

  4. Was Fetal Ultrasound done?

  5. Finding of ultrasound:

  6. Received Yellow Fever Vaccine:

  7. Received Japanese Encephalitis Vaccine:

  8. Fever:

  9. Rash:

  10. Type:

  11. Additional Clinical Symptoms:

  12. Specimen Type:

  13. Leave This Blank:

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