OUTBOUND PCR Travel Test For COVID-19 (Shoppers Drug Mart #1377 at Bloor & Dovercourt)

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Please complete the information below of how you would like your result form to display, as well as complete your assessment prior to the test

PLEASE ENSURE THERE ARE NO SPELLING ERRORS AND ALL INFORMATION IS CORRECT!

PCR COVID-19 Test MUST be completed AT LEAST 30 HOURS before flight departure (FOR OUTBOUND TEST)

It is YOUR RESPONSIBILITY to ensure the identification type meets the requirements for what you need the test for (for travel it is usually your passport). You must bring this identification in and show it to the pharmacy when receiving your test.

This form is only for this specific location: Shoppers Drug Mart #1377 at Bloor & Dovercourt (958 Bloor St. W, Toronto, On, M6H 1L6)

PATIENT INFORMATION

Must match exactly to the identification you will be providing and showing. It is your responsibility to ensure the identification type meets the requirements for what you need the test for (for travel it is usually your passport). You must bring this identification in and show it to the pharmacy when receiving your test.

First Name *

Must match exactly to the identification you will be providing and showing

Middle Name

Must match exactly to the identification you will be providing and showing (leave blank if your document does not show a middle name)

Last Name *

Must match exactly to the identification you will be providing and showing

Date of Birth *

Must match exactly to the identification you will be providing and showing

YYYY

Phone number *

Date of Test *

Date your test is scheduled

YYYY

Time of Test *

Time the test is scheduled for (Use 24 hour time)

Time

Address *

Postal Code *

Gender *

Male

Female

Undisclosed

Flight Departure Date *

For OUTBOUND PCR COVID-19 Test your Test MUST be completed AT LEAST 30 HOURS before flight departure (FOR INBOUND TEST PLEASE ENTER TODAY'S DATE)

YYYY

Flight Departure Time *

(Use 24 hour time) PCR COVID-19 Test MUST be completed AT LEAST 30 HOURS before flight departure. (FOR INBOUND TEST PLEASE ENTER THE CURRENT TIME)

Time

Flight Destination

FOR INBOUND TEST ENTER WHERE YOU ARE FLYING FROM

SCREENING QUESTIONS

If YES to any of the below questions, do not continue. Please advise the Patient to proceed to a COVID-19 assessment center for testing.

Question 1 *

Has the Patient previously received a positive test result for COVID-19?

Yes

Question 2 *

Are you experiencing any of the following symptoms (any/all that are new, worsening, andnot related to other known causes or conditions you already have): fever and/or chills, cough or barking cough (croup), shortness of breath, sore throat, difficulty swallowing, runny or stuffy/congested nose, decrease or loss of taste or smell, pink eye, headache, digestive issues like nausea/vomiting, diarrhea, stomach pain, muscle aches, extreme tiredness, falling down often?

Yes

Question 3 *

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

Yes

Question 4 *

In the past 14 days, have you been identified as a close contact of someone who is confirmed as having COVID-19? A close contacts is defined as: A person who provided care for the Patient, including healthcare workers, workers, family members or other caregivers, or who had other similar close physical contact or who lived with or otherwise had close, prolonged contact with a probable or confirmed case while the case was ill.

Yes

Question 5 *

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

Question 6 *

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No"

Yes

Question 7 *

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

CONSENT, ACKNOWLEDGEMENT & CONFIRMATION:

The patient and/or their agent has verbally confirmed that the responses provided above to the patient assessment questions are true to the best of the patient’s and/or their agent’s know ledge, and acknowledges that if any of such responses are untrue, they may be found to be liable for any resulting harm that is caused.
The patient and/or their agent agree to having the responses provided by them to the above patient assessment questions being used to assess whether a COVID-19 test w ill be recommended, and if the recommendation is that a COVID-19 test not be administered, the patient and/or their agent agree to accept such recommendation.
The patient and/or their agent acknowledge and agree that no representation or warranty has been made about the timing of the completion of the COVID-19 test, nor has any representation or warranty been made stating that a negative result of the COVID-19 test will result in the patient and/or their agent gaining admission to the jurisdiction to which the patient and/or their agent intends to travel. furthermore, the patient and/or their agent acknowledge and agree that in no event shall shoppers, its affiliates, directors, officers, employees, franchisees or agents bear any liability for any losses resulting from the patient and/or their agent’s inability to gain, or any delay in the gaining of, admission to the jurisdiction to which the patient and/or their agent intends to travel.

Question 8 *

Patient and/or their agent has confirmed that COVID-19 testing appointment time is at least 30 hours from Flight Departure Time (FOR INBOUND TESTING ANSWER "YES")

Yes

Question 9

(If Applicable) Patient and/or their agent requests to email the Lab Requisition to the Pharmacist to be printed and acknowledges that email is not a secure mechanism to transfer PHI. (N/A = Not Applicable)

N/A

Yes

Clear selection

Consent Provided by *

Patient (Over 18 Years Old)

Patient’s Agent (Parent or Guardian)

Agent's Name

if Applicable (leave blank if no agent)

We take your privacy seriously and takes measures to protect the privacy of the information you provide. However, the privacy and security of this service cannot be guaranteed. By providing your information through this service, you acknowledge this risk. *

By checking this box, I confirm the accuracy of the information I have provided, acknowledge the information regarding privacy and security and wish to proceed.

Required

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