Pre-register for COVID Assessment Centre (Bancroft/Belleville/Trenton Only)

Do you consent, understanding that unencrypted email carries an inherent risk of disclosure to third parties, to the use of email for the purpose of sending confirmation of your Preregistration Status for your COVID-19 Assessment Centre visit?”*

Yes

What is your preferred Assessment Centre location? *

Belleville

Trenton

Bancroft

Please enter your Ontario Health Card number. If you don't have a health card, please explain (e.g. military, out of country, other).*

Please enter the version code on your health card number. If you don't have a health card, enter n/a. *

Note: Please enter your name as it appears on your health card.

First Name*

Middle name. (As it appears on health card) *

Last Name*

Address*

Address 2

City*

State/Province*

Zip/Postal Code*

Country

Email Address*

Phone*

Birthday*

Month Day Year

Gender*

Female

Male

X

Marital Status*

10 Characters Remaining

Family Doctor (include first and last name). Enter n/a if you don't have a family physician.*

Are you experiencing any symptoms? (Please ensure you have completed the self-assessment and meet the latest provincial guidelines for testing. Visit the COVID-19 page of our website – www.qhc.on.ca for more information.)*

Yes

No

Please enter any additional symptoms not listed.

What was the date of your first symptom?

Were you exposed to an individual with a probable or confirmed case of COVID-19? *

Yes

No

If you were exposed to an individual with a probable or confirmed case, what was the date of the exposure?

Have you traveled out of Ontario or Canada in the last 14 days? *

Yes

No

If you have traveled, where did you go?

If you have traveled, what date did you return?

Please enter the name of an emergency contact or next of kin. *

Please enter the contact phone number for your emergency contact or next of kin. *

What is your relationship with the emergency contact or next of kin? *

What is your preferred date for testing? *

As soon as possible

Future Date

Do you need to have your swab on a specific date? Please enter your preferred date and time (am or pm).

Please read the following legal requirements for self-isolation and check each box to indicate you've read and understood each requirement.*

People with COVID-19 symptoms must self-isolate both before testing and while waiting for test results

All household members must isolate until the symptomatic person receives a negative test result (or alternate diagnosis)

People sent for testing as a contact of someone with COVID-19 must self-isolate for 14 days regardless of test results

The minimum fine for violating self-isolation orders is $750

For more information please read the Class Order issued by the Medical Officer of Health pursuant to Section 22 (5.0.1) of the Health Promotion and Protection Act

YOU MUST COMPLETE A SEPARATE FORM FOR EACH PERSON REQUIRING TESTING.

Thinking back before COVID, are your symptoms bad enough that you would have made an appointment to see your local physician/nurse practitioner, or attend a walk-in clinic? (For data tracking purposes only)*

Yes

No