COVID-19 Virus Test Screening Form
If you do not have a health card or if you have the old red/white health card please call us at (519) 895-8989. If you book with us and try to get tested elsewhere you may have a problem. Please call us to cancel first.
Patient Information
First Name (as written on Health Card)
*
Last Name (as written on Health Card)
*
Date of Birth (yyyy/mm/dd)
*
/
Year
/
Month
Day
Date
Sex:
*
M
F
Health Card No. (including last two letters)
*
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Symptom Status:
*
Asymptomatic - No Symptoms
Symptoms
Select all that apply to you
*
I am a First Nation / Inuit / Metis and/or an invidiual travelling into these communities for work
I am a close contact and people in the context of confirmed or suspected outbreaks in highest risk setting (e.g. hospital, nursing home, correctional facility) as directed by Regional of Waterloo Public Health
On admission/transfer to or from hospital or congregate living setting
People aged 60 years and older who have less than 3 doses of COVID-19 vaccine
Select all that apply to you
*
I am a PATIENT-FACING Healthcare Worker
Staff/Volunteer/Resident/Inpatient/Essential Care Provider in a Hospital Setting
Staff/Volunteer/Resident/Inpatient/Essential Care Provider in a Congregate living setting (Long-Term Care, Retirement Homes, First Nation elder care lodges, group homes, shelters, hospices and correctional institutions)
I am a household member of a worker in highest risk setting
I am a temporary foreign worker in a congregate living setting
I am pregnant
I am a patient seeking emergency medical care at the discretion of the treating clinician
I am underhoused or homeless
I am a First Responder
I work in a correctional facility
I am an immunocompromised outpatient (e.g. transplant patient)
Investigation or Outbreak Number (provided by Public Health/School/etc)
Did you receive a positive with a rapid COVID-19 test?
Yes
No
Travel History
Have you been outside Ontario or Canada?
Have you recently travelled?
Yes
No
Travelled to (country/place)
Date of Travel (yyyy/mm/dd)
/
Year
/
Month
Day
Date
Date of Return (yyyy/mm/dd)
/
Year
/
Month
Day
Date
Exposure History
Exposure to probable, or confirmed case of COVID-19?
Yes
No
Exposure details (who, what, where, etc...)
Date of symptom onset of contact who you were exposed from
/
Year
/
Month
Day
Date
Specimen Collection Date (yyyy/mm/dd)
*
/
Year
/
Month
Day
Date
COVID-19 Vaccination Status
Please choose one:
*
Received ALL required doses
Unimmunized / only 1 dose
Unknown
Clinical Information
Do you have symptoms? if you do, what are they?
What are your symptoms?
Fever
Pneumonia
Cough
Sore Throat
Are you pregnant?
Chills
Shortness of Breath
Difficulty swallowing
Runny nose
Stuffy or congested nose
Lost sense of taste or smell
Pink eye
Nausea/vomiting
Diarrhea
Muscle Aches
Extreme tiredness
Falling down often
Headache
Children - Barking Cough (croup)
Children - Sluggishness
Children - Lack of appetite/difficulty feeding
Other
Onset of Symptoms (yyyy/mm/dd)
/
Year
/
Month
Day
Date
REQUESTING PHARMACIST
LICENSE #
PHARMACY NAME
Type a question
Type a question
Type a question
Anterior Nasal
Anterior Nare
Type a question
Type a
COVID-19 Virus
Assessment Centre
Once you hit submit, your screening questionnaire will be sent to the Pharmacy for review. If deemed eligible for the Publically Funded PCR Test you will be contacted via email/phone.
You may call the Pharmacy at 519-895-8989 if you have any questions.
Submit
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