L&A Hospital Covid Assessment Center Public Appointment Request

Please answer these questions to request an appointment for a Covid test.

Our team will then contact you to offer a date/time for your test. If you are requesting a test for multiple persons, please fill out one request per person. Please note that the ministry limits the testing of individuals without symptoms to specific populations.

1. First Name of the person to be tested (as shown on health card): *

2. Last Name of the person to be tested (as shown on health card): *

3. Date of Birth (DD/MM/YYYY): *

4. Health Card # with version code (nnnnnnnnnn-aa): *

5. Gender (as shown on health card):?

F
M
X

6. Home Street Address: *

7. City: *

8. Postal Code (A2A 2A2) : *

10. Preferred contact phone number: *

11. If the person to be tested is under 18 years, please enter the name of the adult responsible for them.

12. If we can send an appointment confirmation by email, please enter the preferred email:

email:
Confirm email:

13. Family Doctor/Nurse Practitioner name and location: (i.e. Dr Roger Smith, Napanee) *

Regarding the person requiring the COVID-19 test, have they / you:

14. Been referred by Public Health? *

Yes
No

If Yes, please enter outbreak #:

15. Had a covid test before? *

Yes
No

16. Experienced any of the following symptoms? (Can select multiple choices) *

Other symptoms that make you feel concerned for COVID-19?

17. Based on those symptoms, are you requesting also an assessment with a physician?

Yes
No

18. Travelled outside of Canada in the past 14 days? *

Yes
No

If yes, when and what location:

19. Been in close contact with a confirmed/probable case of Covid-19? *

Yes
No

If Yes, when were you in contact:

20. Is a health care worker? *

Yes
No

If yes, where do you work?

21. Attending/working in school or daycare? *

Yes
No

If yes, school/daycare name:

22. Been advise to be tested because of a requirement from a Long term care, group home or homeless shelter? *

Yes
No

23. Preferred time period for appointment (e.g. tomorrow am or Today after 3pm). we will try to accommodate your preference.

24. Any other information we should know regarding this appointment booking?

We are committed to respecting your privacy rights as a guest to the LACGH Covid Assessment Centre Registration Form.

Our practices are consistent with Ontario’s privacy legislation. When you use this form, we collect only what is necessary to provide the health care needed for booking a COVID appointment. We take the necessary precautions to protect it from unauthorized access, linkage, disclosure or alteration.

For questions or comments regarding this privacy statement, please reach out privacy@lacgh.napanee.on.ca