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COVID-19 Tests
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Location
Minor Ailments
Refill

COVID-19 Tests
Contact Us
Location
Minor Ailments
Refill

COVID-19 Test Requisition

Covid 19 Testing Requisition

Please fill out the following information and our team will get in touch with you to continue the application process.

Personal Information

Name(Required)

First Last

Phone(Required)

Email

Birthday(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Health Card

Address

Street Address City Province ZIP / Postal Code

Vaccination Status and Travel

Vaccination Status(Required)

Received all required doses >14 days ago

Unimmunized / partial series / ≤14 days after final dose

Unknown

Are you travelling in the next 2 weeks(Required)

Yes

No

Travel Details

Destination

Departure

MM slash DD slash YYYY

Return

MM slash DD slash YYYY

Exposure

Have you been exposed to a probable or confirmed case?(Required)

Yes

No

Date of exposure

MM slash DD slash YYYY

Symptoms

Symptoms Type(Required)

Asymptomatic

Symptomatic

Date Symptoms Started(Required)

MM slash DD slash YYYY

Symptoms Experienced(Required)

Fever

Pnuemonia

Cough

Sore Throat

Pregnant

Other Symptoms

Other Symptoms(Required)

Get In Touch With Us

905-845-5595
Contact Us

Visit Us

635 Fourth Line, Oakville, ON L6L 5W4

Hours

Monday - Friday: 9:00 am - 5:30 pm

Saturday: 9:30 am - 12:30 pm

Sunday: Closed

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