COVID-19 INVESTIGATION FORM 2021

DO NOT complete this form if taking a 5-day test for the Bahamas Government.

Show up to the lab at your assigned appointment time.
Please make your appointment before filling out this form.

Call 322-7994 for appointment.
The information that you provide on this form will be provided to the Government of the Bahamas for surveillance and statistical purpose. Information should be accurate and precise Please select "I Agree" to continue. *

I Agree

COVID -19 Request Form
Patient Information
Are you completing this form on behalf of someone else? *
Reason for Testing *
Are you/patient experiencing any symptoms? *
Name *

First Name Last Name
Sex *
Date of Birth

Day Month Year
Date
Address in the Bahamas.
House Number
*

Street Name/Hotel Name

City/Settlement/Cay

Island Country
Mobile *

Area Code or Country Code Phone Number
Home *

Area Code or Country Code Phone Number
Work *

Area Code or Country Code Phone Number
Email *
example@example.com
Government ID *
Number *
Nationality *
Place of employment *
Occupation *
Vaccination Status *
Last Vaccination Date *

Day Month Year
Date
Vital Status
Were you or the patient hospitalized *
Name of Hospital *
Date of Hospitalization *

Day Month Year
Date

Date of onset illness *

Day Month Year
Date
Abdominal Pain *
Chills *
Diarrhea *
Dry Cough *
Fatigue *
Fever *
Headache *
Myalgia *
Losst of taste *
Loss of smell *
Shortness of breath *
Vomiting *

Travel History
Domestic Travel within the last 14 days? *
Date of Domestic Travel *

Day Month Year
Date
City *
Island *
International Travel within the last 14 days? *
*

Street Address

Street Address Line 2

City State

Country
Date of International Travel *

Day Month Year
Date
Contact with Known Case *
Date of exposure *

Day Month Year
Date
Should be Empty: