Grand Bend Area Community Health Centre

Form Preview

COVID-19 Test Appointment Request Form

Please complete an appointment request form for each person, each time a COVID-19 test is required.

First Name *

Last Name *

Address *

Address

City

Province

Postal Code

Country

Date of Birth *

Ontario Health Card Number *

Reason for Test Request *

I have COVID-19 symptoms

I have been exposed to a COVID-19 positive case

I have returned from travelling out of country

To attend my workplace

To visit a long-term care or retirement home

Other information to help triage your appointmentOther information to help triage your appointment

Select all that apply.

Would you like an appointment at the same time as another person in your vehicle? *

Click the arrow at the right to select response.

Phone *

Provide the best phone number at which to reach you during business hours.