COVID-19 PCR TESTING Please fill out the following questionnaire to determine your eligibility for COVID testing. Kindly provide accurate information to ensure appropriate prioritization of testing resources. Your First Name Your Last Name Your Address Email Your ZIP / Postal Code Daytime Phone Number / Home Phone – format (999) 999-9999)** Health Card Number if none, enter passport #* Birth date* Gender*MaleFemale Age Category60 years of age and older18 years of age and older with comorbidities18 years of age and older, unvaccinated or incomplete vaccination18 years of age and older, completed primary vaccination series more than 6 months ago, and no SARS-CoV-2 infection in the past 6 monthsImmunocompromised individualsPregnant individualsNone of the above Are you a patient seeking emergency medical care or an outpatient for whom a diagnostic test may guide clinical management?YesNo Are you a patient-facing healthcare worker?YesNo Are you a staff member, volunteer, resident/inpatient, essential care provider, or visitor in a highest risk setting?YesNo Are you a household member of staff in a highest risk setting or a patient-facing healthcare worker?YesNo Are you a home or community care worker?YesNo Are you an International Agriculture Worker in a congregate living setting?YesNo Are you underhoused or experiencing homelessness?YesNo Are you a first responder, including fire, police, or paramedic personnel?YesNo Are you from a First Nation, Inuit, Métis community, or do you self-identify as First Nation, Inuit, or Métis?YesNo Are you planning to travel into a First Nation, Inuit, Métis community for work? (Yes/No)YesNo Have you been admitted to or transferred from a hospital or congregate living setting recently?YesNo Are you currently in the context of a confirmed or suspected outbreak in a high-risk setting as directed by the local public health unit?YesNo Do you have written prior approval for out-of-country medical services from the General Manager, Ontario Health Insurance Plan (OHIP)?YesNo Do you have a scheduled surgical procedure requiring a general anesthetic within the next 24-48 hours? YesNo Are you a newborn born to a parent with confirmed COVID-19 within 24 hours of delivery?YesNo Are you planning to undergo treatment for cancer or hemodialysis within the next 24-48 hours, as advised by your treating clinician?YesNo Are you a staff member of a highest risk setting who has had close contact with someone with COVID-19 symptoms or a positive test within the last 10 days?YesNo Please enter your initials for consent Date of Signature I AGREE TO COVID-19 PCR TESTING GUIDELINES Get in touch Come and visit our quarters or simply send us an email anytime you want. We are open to all suggestions from our audience. ADDRESS 1501 Ellesmere Road Scarborough, ON M1P 4T6 Call us Tel: 647-351-4400 Fax: 647-351-4405 Text: 647-806-3784 Write us info@oasisdrugmart.com oasisdrugmart@gmail.com
