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1
Patient Name
*
This field is required.
First Name
Last Name
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2
Patient Date of Birth
*
This field is required.
Enter Patient date of birth in the following format: DD/MM/YYYY
Enter patient date of birth
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3
Private E-mail
*
This field is required.
This email will be used to communicate your test result status
example@example.com
Confirm Email
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4
Do you have a Provincial Health Card?
*
This field is required.
Yes
No
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5
Which province is your health card from?
*
This field is required.
Ontario
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Prince Edward Island
Quebec
Saskatchewan
Ontario
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Prince Edward Island
Quebec
Saskatchewan
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6
Enter your Ontario health card number
*
This field is required.
format: 9999999999-aa
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7
Enter your British Columbia health card number
*
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8
Enter your ALBERTA health card number
*
This field is required.
Format: 99999-99999
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9
Enter your Manitoba health card number
*
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10
Enter your New Brunswick health card number
*
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11
Enter your Newfoundland and Labrador health card number
*
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12
Enter your Nova Scotia health card number
*
This field is required.
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13
Enter your Prince Edward Island health card number
*
This field is required.
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14
Enter your Saskatchewan health card number
*
This field is required.
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15
Private Phone Number
*
This field is required.
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16
Select a test type
*
This field is required.
Blood
Urine
Biopsy
PAP Test
Swab
Stool
X-Ray
Ultrasound
Specialized Test
Blood
Urine
Biopsy
PAP Test
Swab
Stool
X-Ray
Ultrasound
Specialized Test
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17
Select a Blood Test
*
This field is required.
Any Blood test report
Alk. Phosphatase
ALT
Any Immunology
Bilirubin
Biochemistry
Blood Culture
CBC (Complete Blood Count)
CK
Creatinine
Ferritin
Glucose
HbA1C
Hematology
Hepatitis A
Hepatitis B
Hepatitis C
INR (Prothrombin Time)
Lipid (Cholesterol)
Measles
Mumps
Pregnancy Test (Blood)
Prenatal Antibody
Rubella
Sodium/Potassium/Chloride
STD-Any STD tests
STD-Chlamydia (Blood)
STD-Gonorrhea (Blood)
STD-HIV (Blood)
STD-Other
STD-Syphilis (Blood)
TSH
Uric Acid
Varicella/Chicken Pox
Viral Hepatitis
Vitamin B12
Other Blood Test
Any Blood test report
Alk. Phosphatase
ALT
Any Immunology
Bilirubin
Biochemistry
Blood Culture
CBC (Complete Blood Count)
CK
Creatinine
Ferritin
Glucose
HbA1C
Hematology
Hepatitis A
Hepatitis B
Hepatitis C
INR (Prothrombin Time)
Lipid (Cholesterol)
Measles
Mumps
Pregnancy Test (Blood)
Prenatal Antibody
Rubella
Sodium/Potassium/Chloride
STD-Any STD tests
STD-Chlamydia (Blood)
STD-Gonorrhea (Blood)
STD-HIV (Blood)
STD-Other
STD-Syphilis (Blood)
TSH
Uric Acid
Varicella/Chicken Pox
Viral Hepatitis
Vitamin B12
Other Blood Test
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18
Select a Urine Test
STD-Chlamydia (Urine)
STD-Gonorrhea (Urine)
Urine Bacterial Culture
Urinalysis (Chemical)
Urine Pregnancy
Albumin/Creatine Ratio (Urine)
Other Urine Test
STD-Chlamydia (Urine)
STD-Gonorrhea (Urine)
Urine Bacterial Culture
Urinalysis (Chemical)
Urine Pregnancy
Albumin/Creatine Ratio (Urine)
Other Urine Test
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19
Select a Swab Test
Any Swab test
Cervical
Fungal
Rectal
Sputum
STD Test (Swab)
Throat
Vaginal
Wound Culture
Other Swab test
Any Swab test
Cervical
Fungal
Rectal
Sputum
STD Test (Swab)
Throat
Vaginal
Wound Culture
Other Swab test
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20
Select a Stool Test
Stool Ova & Parasite
Stool culture
Stool Pinworm Test
Fecal Occult Blood Test (FOBT)
Colon Cancer Check (CCC)
Other Stool Test
Stool Ova & Parasite
Stool culture
Stool Pinworm Test
Fecal Occult Blood Test (FOBT)
Colon Cancer Check (CCC)
Other Stool Test
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21
Select X-Ray Testing Location
*
This field is required.
Done On-Site
Done at Outside Facility
Done On-Site
Done at Outside Facility
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22
Select Ultrasound Location
*
This field is required.
Done On-Site
Done at Outside Facility
Done On-Site
Done at Outside Facility
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23
Specialized Tests
*
This field is required.
Done at an Outside Facility such as Hospital
MRI
CT
Mammogram
Biopsy
Sleep Study
Other
MRI
CT
Mammogram
Biopsy
Sleep Study
Other
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24
When did you do this test?
*
This field is required.
If you do not remember the exact date, please enter an approximate time (i.e 1 week ago, 1 month ego etc.)
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25
Type the name of test report that you are looking for
If the test report that you are looking for is not a part of previous list, specify the name of test you are looking for
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