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

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This webform is for use to pre-register for the Community Assessment Centres located in Bancroft, Belleville and Quinte West. Please book an appointment for the Assessment Centre located in Picton by clicking here or calling 613-813-6864.

Complete all required fields in the COVID-19 Community Assessment Centre Pre-registration form in order to submit the form. This form must be completed separately for each person in your family requiring a COVID-19 test. Within 24 hours you will be provided with instructions and directions for attending a local assessment centre.

Quinte Health Care has made an exception to allow the use of unencrypted email for the purpose of preregistering during the declared emergency. In order for QHC to use unencrypted email, we must obtain the consent of the patient for this purpose. If you do not consent, please pre-register by phone at 613-961-5544.

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

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

Please select any symptoms you are experiencing.

Fever

Cough

Fatigue

Sore Throat

Headache that is new or unusual

Shortness of Breath

Runny Nose

Difficulty Swallowing

Decrease/Loss of taste or smell

Pink Eye

Digestive Issues

Falling Down Often

Sluggish or Lack of Appetite

Please enter any additional symptoms not listed.

What was the date of your first symptom?

Are you in any of these at-risk groups?

Getting treatment that compromises (weakens) your immune system (for example: chemotherapy

medication for transplants

corticosteroids

TNF inhibitors)

Having a condition that compromises (weakens) your immune system (for example: lupus

rheumatoid arthritis

immunodeficiency disorder)

Having a chronic (long-lasting) health condition (for example: diabetes

emphysema

asthma

heart condition

COPD)

Regularly going to a hospital or health care setting for a treatment (for example: dialysis

surgery

cancer treatment)

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

Yes

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

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).

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