Covid-19 Test Request Form

Covid-19 Test Request Form

OakTree Medical Center
In the wake of Covid-19, OakTree Medical Center is offering complete COVID-19 Test Services. Please ensure that the information you give is accurate and complete. If you have any symptoms associated with COVID-19, please contact your medical practioner.
Have you had a positive COVID-19 Test or diagnosis in the last 14 days? *

Yes No
Name *

First Name Last Name
Date of Birth *

Day Month Year
Date
Phone Number (Primary) *
Phone Number (Secondary)
Email *

Confirmation Email example@aipsolutions.tech

IMPORTANT! Please provide your name as is written on your government-issued identification.
Name *

First Name Last Name
Gender *

Male Female
Date of Birth *

Day Month Year
Date
Age *
NIB Number
Email Address *

Confirmation Email example@aipsolutions.tech
Phone Number (Primary) *
Phone Number (Secondary)
Residential Address *

Street Address

Street Address Line 2

City Island / State / Province

Postal / Zip Code
Employment Status *

Full-time Employed Part-time Employed Self-Employed Unemployed
Name of Employer *
If employed, state your employer
Employer Phone Contact *
Next of Kin *
Relationship *
Next of Kin Phone (Primary) *
Next of Kin Phone (Secondary)

Reason for Covid-19 Test *

Physician Referral Return to Work Travel Exposure to Covid-19 positive patient Exhibiting symptoms of Covid-19 Other
Physician Name *
Provide the name of your referring Physician, or if not referred, your personal Physician.
Upload Physician referral letter or requisition

Cancel of

Price of test: $125.44 (VAT Included)
Select Desired Appointment Slot *
I agree to collect my test results from Oaktree Medical Center no later than 36 hours from testing. *

I agree
I acknowledge that I completed this form myself, and that the information I have provided in this form is accurate and complete, including all contact and address information. *

I agree
I understand that should my results come back positive, OakTree Medical Center is obligated to alert The Bahamas Ministry of Health officials. *

I agree
I understand that following the submission of this form, I will be sent via email a link to pay my charges online. I understand that payment (online or physical) is mandatory prior to my visit. *

I agree
I understand that specimens can take 24-36 hrs to process, and that results can be delayed for reasons including (but not limited to) the need for a specimen to be re-processed, incomplete or accurate information provided by the patient, public health notification requirements, etc. Should delays occur, OakTree Medical Center is not responsible for any travel-related delays or cancellations as a result. *

I agree
Signature *

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