Asymptomatic Covid Testing Assessment Form
Intrepid Pharmacy is pleased to offer Private Asymptomatic Covid Testing. The information submitted will be required for your certificate of test results. **After submitting this form, please return to the previous page to book your appointment.**
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Email *
First Name and Middle Name (as it appears on passport) *
Last Name (as it appears on passport) *
Date of Departure
MM
/
DD
/
YYYY
Time of Departure
Time
:
Gender *
Required
Date of Birth *
MM
/
DD
/
YYYY
Street Address (include a unit number if applicable) *
Postal Code *
City *
Province *
Country *
Phone Number *
What kind of Covid Test do you need? (please check on required test with your airline or local authorities of your destination) *
1. Are you experiencing any of the following symptoms? *
Required
In the past 14 days, did you return from travel outside of Canada? *
Required
In the past 14 days, have you been identified as a close contact of someone who is confirmed as having Covid-19? [A close contact is defined as a person a) who provided care for the patient, including healthcare workers, family member or other caregivers, or b) who had other similar close contact or c) who lived with or otherwise had close, prolonged contact with a probable or confirmed case while the case was ill.] *
Required
Have you been advised to get tested for Covid-19 by your local public health unit due to exposure to a confirmed case or as part of an outbreak investigation? *
Required
Have you been advised to get tested for Covid-19 through an exposure notification through the Covid-19 app? *
Required
Are you over the age of 70 and experiencing any of the following: delirium, unexplained or increased number of falls, acute functional decline, worsening chronic conditions? *
Required
A copy of your responses will be emailed to the address you provided.
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