SHHF - Eform

Covid Assessment Clinic Registration

*Do you consent, understanding that unencrypted email carries an inherent risk of disclosure to third parties, to the use of email for the purpose of sending confirmation of your Preregistration Status for your COVID-19 Assessment Center visit?”:

Do you consent, understanding that unencrypted email carries an inherent risk of disclosure to third parties, to the use of email for the purpose of sending confirmation of your Preregistration Status for your COVID-19 Assessment Center visit?”

Yes

No

*Please enter your Ontario Health Card number. If you don't have a health card, please explain (e.g. military, out of country, other).:

*Please enter the version code on your health card number. If you don't have a health card, enter n/a. :

Note: Please enter your name as it appears on your health card.

*First Name:

*Middle name. (As it appears on health card) :

*Last Name:

*Address:

*City:

*State/Province:

*Zip/Postal Code:

*Country:

*Email:

*Phone:

ext.

*Birthday:

*Gender:

Gender

Female

Male

X

*Marital Status:

*Family Doctor (include first and last name). Enter n/a if you don't have a family physician.:

Are you experiencing any symptoms? (Please note as of Sept. 24, testing guidelines changed to reduce testing of individuals not experiencing symptoms. We ask that you please refrain from getting tested unless you meet the criteria listed on the COVID-19 page of our website – www.psfdh.on.ca):

Are you experiencing any symptoms? (Please note as of Sept. 24, testing guidelines changed to reduce testing of individuals not experiencing symptoms. We ask that you please refrain from getting tested unless you meet the criteria listed on the COVID-19 page of our website – www.psfdh.on.ca)

Yes

No

Please select any symptoms you are experiencing. :

Please select any symptoms you are experiencing.

Fever

Cough

Fatigue

Sore Throat

Headache

Shortness of Breath

Runny Nose

Please enter any additional symptoms not listed.:

What was the date of your first symptom?:

Were you exposed to an individual with a probable or confirmed case of COVID-19?:

Were you exposed to an individual with a probable or confirmed case of COVID-19?

Yes

No

Have you traveled out of Ontario or Canada in the last 21 days? :

Have you traveled out of Ontario or Canada in the last 21 days?

Yes

No

If you have traveled, where did you go? :

If you have traveled, what date did you return? :

Please enter the name and number of emergency contact:

If you need to schedule a test for a future date (such as testing required before surgery), please enter your preferred date and time (am or pm).:

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COVID-19 Assessment

Covid Assessment Clinic Registration

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Search Our Site...

COVID-19 Assessment

Covid Assessment Clinic Registration

We are processing your submission.Please do not press back or refresh.

We are processing your submission.
Please do not press back or refresh.