COVID Assessment Centre Intake Form

Please fill out this form and one of our nurses will contact you for an appointment. We are open from Monday to Friday and will try to respond the same day. For emergencies, please go to the nearest emergency department.

Please do not come without an appointment, as our doors are locked and you will not be seen.

Demographic information

First and last name (as written on your health card) *

Date of birth (dd/mm/yyyy) *

Age *

Sex *

Male Female

If you checked female, are you pregnant?

Yes No

Street Address *

City *

Postal code *

Cell phone number *

Email address *

Health Card Number and version code *

Name of your family physician *

Have you previously been tested at our assessment centre? *

Yes No

Travel and contact history

Have you travelled outside of Canada in the last 14 days? *

Yes No

If yes, please fill in the dates below.

Date of travel (dd/mm/yyyy)

Date of return to Canada (dd/mm/yyyy)

Have you been in close contact with someone who has tested positive for COVID-19 in the last 14 days? (A close contact refers to a contact with a person at a distance of less than 2 meters for a period of more than 15 minutes) *

Yes No

Are you a frontline healthcare worker? *

Yes No

Do you have an investigation/outbreak number? *

Yes No

If yes, indicate the number:

COVID-19 Vaccination Status

Vaccination status *

I have received both doses of the COVID-19 vaccine more than 14 days ago. I have received only 1 dose of the COVID-19 vaccine more than 14 days ago. I am not vaccinated / I have received a COVID-19 vaccine less than 14 days ago.

Testing eligibility

Why do you want to be tested today? *

I have COVID-like symptoms. I do not have symptoms but require a COVID-19 test for visitation in a Retirement or Long-Term Care Facility. I do not have symptoms but Public Health requested that I be tested. Other:

Symptoms

Choose any/all that are new, worsening, and not related to other known causes or conditions.

Fever and/or chills

Difficulty breathing or shortness of breath

Cough

Sore throat, trouble swallowing

Runny nose/stuffy nose or nasal congestion

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, abdominal pain

Extreme tiredness, sore muscles

Other symptoms not listed :

Date symptoms started :

In order to avoid delays in obtaining your COVID test results from the ministry’s website, verify that ALL information submitted is complete and accurate.