COVID-19 Test Requisition First Name* Last Name* Date of Birth* Sex* MaleFemale Address* Postal Code (A1B 2C3)* Phone Number* Health Card #* Vaccination Status* Received all required doses >14 days agoUnimmunized / partial series / ≤14 days after final doseUnknown If traveling Destination Leaving on Returning on Clinical Info Asymptomatic Symptomatic Date Symptoms Started Fever PneumoniaCough Sore Throat Pregnant Other Symptoms Other Symptoms Exposed to probable or confirmed case YesNo If Exposed Date of exposure Event Outbreak Number Date of symptom onset of contact FOR THE SAFETY OF THE STAFF AND OTHER CLIENTS,PLEASE DO NOT COME INSIDE THE PHARMACY UNLESS INSTRUCTED TO DO SO BY A PHARMACY STAFF MEMBER. PLEASE STAY IN YOUR CAR AND CALL THE PHARMACY WHEN YOU'RE OUTSIDE
