“A passion for better medicine.”
Emerald Bay Shopping Center, Tel: (242)358-4042, Exuma, Bahamas.
COVID-19 Test Requisition
Patient Information
Name*
First Name Last Name
Sex*
Date of Birth*
Month Day Year
Phone Number*
Area Code Phone Number
Home Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Notify E-mail Address
example@example.com
Identification Type*
Identification Number*
Upload a copy government issued identification if completing this form via a computer.(Laptop or desktop)
Browse Files
Cancelof
Take Photo of a government issued identification if completing this form via a mobile device.(Cell phone or tablet).

	Yes	No
Tested positive for Covid-19 by a molecular (PCR) test

Terms & Conditions Acknowledgement
By clicking i agree, you indicate that you, as the patient or legal guardian of the patient, agree:
1. to the best of my knowledge, all information submitted is accurate;
2. to follow up with my regular medical provider for ongoing care (if applicable);
3. to the Terms of Service and Consent to Di-Ara Comprehensive Medical Clinic.
Signature*
Clear
Name*
First Name Last Name
Please verify that you are human*
Should be Empty:

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

	Yes	No
Experienced loss of smell or taste
Experienced shortness of breath, weakness or lethargy?
Experienced lightheadedness or dizziness
Experienced vomiting or diarrhea, slurred speech or seizure

	Yes	No
Been in contact with someone who wasdiagnosedwith COVID-19?
Been in close contact with someone who had COVID-19symptoms?
Traveled internationally or taken a cruise

COVID-19 Test Requisition

Patient Information

	Yes	No
Cough
Shortness of breath of difficulty breathing