COVID-19 PCR TESTING

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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

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