COVID-19 PUBLICLY FUNDED PCR TEST SCREENING FORM

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Email *

I consent to the collection, use and disclosure of my personal health information *

yes

Required

FIRST NAME *

LAST NAME *

GENDER *

FEMALE

MALE

HEALTH CARD NO *

DATE OF BIRTH *

YYYY

TELEPHONE NUMBER *

PATIENT ADDRESS *

POSTAL CODE *

RECENT TRAVEL HISTORY IF ANY

TRAVEL DATE

YYYY

RETURN DATE

YYYY

Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other know causes or conditions *

Fever and chills

New onset of cough or worsening

shortness of breath

decrease or loss of sense or taste

if adult> 18 yrs of age : unexplained fatigue/lethargy/malaise/muscle aches ( myalgia)

if adult < 18 yrs oaf age : nausea,/vomiting/diarrhea

What is your vaccination status *

fully vaccinated

not fully vaccinated

You have symptoms of COVID-19 and fall into the following targeted groups? *

hospitalized patients

Patients seeking emergency medical care ,at the discretion of the treating clinician

Patient facing health care workers

Staff/Volunteers, residents/in patients, essential care providers, and visitors in hospitals and congregate living settings

Working in retirement home, long term care ,retirement home

First nations elder care lodges ,group homes, shelters ,hospices

Temporary foreign workers settings

Correctional Settings

Outpatients for whom COVID-19 treatment is being considered-includes those age 70 yrs or older who have a risk factor inluding obesity with BMI>30,dialysis,stage 5 kidney disease,diabetes,cerebral palsy ,intellectual diasbility of any severity ,sickle sick disease ,receiving anti cancer treatment,solid organ transplant ,or aged 50 yrs or older if first nation ,Inuit or Metis with any of those risk factors

Underhoused or homeless

Elementary and secondary students and education staff who received a PCR collection kit through school

Pregnant

Firs responders ( Fire ,Police and Paramedic )

60 and above with less than 3 covid vaccines

70 and above

18 yrs old and above that are immunocompromised

18 yrs old and above with less than 3 covid vaccine and have at least one chronic medical condition

Required

You are eligible under one of the following groups? *

First Nation ,Inuit and Metis or travelling into these communities for work

People on admission /transfer to or from hospital or congregate living setting

High risk contacts in confirmed or suspected outbreaks in high risk setting

High risk contacts in confirmed outbreaks in hospitals , long term care, retirement homes

Individuals,& one accompanying group caregiver with written prior approval for out of country medical services from the General manager,OHIP

Asymptomatic setting in hospital ,long term care, retirement homes & other congregate living settings as per provincial directive

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