Travel Covid Testing Assessment Form

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Intrepid Pharmacy is pleased to offer Travel 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. PLEASE BRING YOUR PASSPORT TO THE APPOINTMENT IF TRAVELLING **

Email *

First Name and Middle Name (as it appears on passport) *

Last Name (as it appears on passport) *

Date of Departure *

YYYY

Time of Departure *

Time

Gender *

Female

Male

Required

Date of Birth *

YYYY

Street Address (include a unit number if applicable) *

City *

Province/State *

Country *

Postal Code/Zip Code *

Phone Number *

What kind of Covid Test do you need? (please check on required test with your airline or local authorities of your destination) *

RT-PCR test ($149)

Rapid Antigen Test ($39)

1. Are you experiencing any of the following symptoms? *

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore Throat

Difficulty swallowing

Decrease or loss of sense of taste or smell

Chills

Headache

Unexplained fatigue/malaise/muscle aches

Nausea/vomiting, diarrhea, abdominal pain

Pink Eye (conjuctivitis)

Runny nose or nasal congestion without other known cause

None of the above

Required

In the past 14 days, did you return from travel outside of Canada? *

Yes

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.] *

Yes

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? *

Yes

Required

Have you been advised to get tested for Covid-19 through an exposure notification through the Covid-19 app? *

Yes

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? *

Yes

Not applicable

Required

A copy of your responses will be emailed to the address you provided.

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