COVID-19 Test Request Form - Grand Bend Area Community Health Centre

COVID-19 Test Appointment Request Form

Please complete an appointment request form for each person, each time a COVID-19 test is required.
Low risk, asymptomatic individuals are not being considered for COVID-19 testing to ensure those at greatest risk are tested.
A member of the COVID-19 Assessment Centre team will call you to book an appointment for a test.

First Name - Please complete form exactly as listed on your healthcare card! *

Last Name - Please complete form exactly as listed on your healthcare card *

Address *

Address

City

Province

Postal Code

Country

Date of Birth *

Ontario Health Card Number *

Reason for Test Request *

I am experiencing COVID-19 symptoms

I have been exposed to a confirmed case of the virus by public health or by the COVID-19 Alert mobile app

I am a resident or worker in a setting that has a COVID-19 outbreak identified by a public health unit

I am part of a targeted testing initiative as directed by the Ministry of Health or the Ministry of Long-Term Care

Pre-surgery/medical procedure

Asymptomatic/no symptomsAsymptomatic/no symptoms

Confirming a positive rapid antigen resultConfirming a positive rapid antigen result

Other (please specify)Other (please specify)

Other concerns and considerations you want us to knowOther concerns and considerations you want us to know

If you like an appointment at the same time as another person in your vehicle - please have them fill out the on-line form also. We require a completed form for each person in your vehicle wanting testing *

Click the arrow at the right to select response. Remember - we require a completed form for each person requiring testing

Phone *

Provide the best phone number at which to reach you during business hours - We will call you back to book an appointment time - please allow for longer call back times during periods of increased testing volumes