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Drive-Through COVID-19 Testing
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COVID-19 Testing Request Form
Panabios
Panabios ID
PA-
Testing Facility
*
Windhoek
Testing Reason
*
- Select -
Hospitalized Patient (Symptomatic)
Truck driver (Cross border)
Health Worker (Symptomatic)
Deceased
Suspected New Case
Quarantine (1st sample)
Quarantine (2nd sample)
Travel (Medical Reasons)
Hospital Admission / Pre-op
Contact tracing (1st sample)
Contact tracing (2nd sample)
Contact tracing (active case)
Travel (Non-medical)
Confirmatory PCR
How did you hear about us?
Social Media (Facebook)
Your Doctor
Word of mouth
Advertisement (Radio, Newspaper, Signage)
Other…
Enter other…
Patient Details
Name(s) *
Surname *
ID / Passport No. *
Date of Birth *
Age
Medical Aid Name
Medical Aid Plan
Medical Aid Number
Gender *
Male
Female
Residential Address *
Nationality - OLD HIDDEN
Nationality *
- Select -
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
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Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d’Ivoire
Denmark
Diego Garcia
Djibouti
Dominica
Dominican Republic
Ecuador
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El Salvador
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Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
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Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
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Guinea-Bissau
Guyana
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Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
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Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR China
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
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Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
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Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
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Norway
Oman
Outlying Oceania
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Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Samoa
San Marino
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
São Tomé & Príncipe
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Cell Nr *
E-mail Address - OLD HIDDEN
E-mail Address *
E-mail Address *
Confirm E-mail Address *
Doctor / Health Care Provider Details
Dr / Facility Name
Contact Number
E-mail Address
Next of Kin Details
Full Name *
Relationship to Patient
Contact Number *
Signs & Symptoms
Symptomatic? *
Yes
No
Symptoms *
Fever (≥38 °C)
Sore throat
Diarrhea
Loss of smell
Chills
Cough
Shortness of breath
Myalgia/body pains
Vomiting
Loss of taste
Other…
Enter other…
Date of Symptom Onset *
Physical Contact with Known COVID-19 Case? *
Yes
No
Unknown
Name & Surname (If Known)
Vaccination Details
Have you received a COVID-19 vaccine? *
Yes
No
When did you receive the vaccine?
Which vaccine did you receive?
- None -
AstraZeneca
Sinopharm
Moderna
Johnson & Johnson
Pfizer
How many doses of the vaccine have you received?
First
First & Second
First, Second & Third
Medical History / Co-morbidities
Co-morbidities
Obesity
Tuberculosis
Chronic Kidney Disease
Diabetes Mellitus
Cardiovascular disease incl. Hypertension
Pregnancy
HIV
Asthma
Chronic Liver Disease
COPD/Chronic Pulmonary Disease
Other…
Enter other…
Previously tested positive for COVID-19?
Yes
No
Date of Confirmation
Submit
