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

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

If you are human, leave this field blank.

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COVID-19 Test Appointment Request Form