All fields with an "*" must be completed including facility contact information. Complete additional fields as applicable. Month, day, and year MUST be entered for all applicable date fields - if uncertain of exact date(s), enter the best estimate and make a note in the "Clinical Notes" section. Please note that incomplete information may require follow up to obtain needed information and this may delay an authorization decision.

You will receive an immediate testing decision based on your responses and CDC's Zika testing guidance at the completion of the form.

Thank you!

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