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 Saturday 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

Full Name *

Date of Birth (d/m/y) *

Age *

Address *

City: *

Postal code *

Preferred contact number *

Email Address: *

Health card number and version code *

Physician *

Have you been previously tested at our assessment centre? *

Yes

No

Travel and contact history

What symptoms are you experiencing?

I do not have any of the symptoms mentioned above, but would like to be tested for COVID-19

Yes

COVID Assessment Centre Intake Form

Demographic information

Travel and contact history

What symptoms are you experiencing?

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