ALBANY COVID-19 Test Request Form

I. Demographic Information

Please complete the required demographic information as per The Bahamas Ministry of Health Guidelines.
Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Age*
Phone Number*

Area CodePhone Number
Secondary Phone Number
Email Address (please enter twice)*

Confirmation EmailNOTE: We recommend the use of personal emails (e.g. Gmail, Hotmail, Yahoo, etc.) instead of company emails.
Residential Address*

House # & Street Address

Street Address Line 2

City/SettlementIsland / State / Province

P.O. Box/Zip CodeCountry
Government ID Type*
Government ID Number*
Nationality*
Reason for Testing*
Company Name
Trip ID
Island of Residence in the Last 14 Days*
Employment Status*
NOTE: Doctors Hospital will not share your test results with your Employer.
Name of Employer*
NOTE: Doctors Hospital will not share your test results with your Employer.
Phone Number of Employer*
NOTE: Doctors Hospital will not share your test results with your Employer.
Next of Kin Name*

First NameLast Name
Next of Kin Relationship*
Next of Kin Phone Number*
Please enter a valid phone number.
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COVID-19 Test Request Form