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Mission Valley CenterSan Diego Fertility Center Egg 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out your travel history in the past 6 months. Provide details for both yourself and your partner in the designated fields.
- Indicate whether you or your partner have experienced any symptoms such as fever, rash, joint pain, or red eyes within the last 6 months by selecting 'Yes' or 'No'.
- Answer if either you or your partner has been infected with the Zika Virus in the last 6 months by marking 'Yes' or 'No'.
- Review and circle 'Yes' or 'No' for travel to Zika risk areas as listed on the CDC website. Ensure you acknowledge this information.
- Finally, confirm if there has been unprotected sexual contact with anyone who has had Zika exposure. Sign and date at the bottom of the form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.8 Satisfied (82 Votes) |
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