Stay home. You need to speak with a healthcare professional by phone and the healthcare professional will advise you on next steps. Assessment Request Form 1 Read First2 About You3 Your Symptoms4 Emergency Contact5 Consent & Submit Read First*Testing will NOT change the course or treatment of the illness of COVID 19. Anyone with respiratory symptoms MUST self-isolate for 10 days regardless of testing. Anyone arriving in Canada MUST self isolate for 14 days. The purpose of the assessment visit is to assess and manage any urgent respiratory symptoms as well as assess, educate and test for COVID 19 as per Provincial Guidelines. It is by all of us working together to SOCIAL distance that will keep our community safe. Thank you for doing your part #stayhome #socialdistance #missionstrong! I understand Legal Name* Legal First Name Legal Last Name Phone*Email* Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code What is your age in years?Are you mobile?YesNoAre you more than 28 weeks pregnant?YesNoAre you a healthcare worker or first responder (fire, police, ambulance)?YesNoDoes your role involve direct patient care?YesNoWill you be arriving by car?YesNo Which symptoms do you have?*Select all that apply Cough High temperature (fever) Shortness of breath or difficulty breathing Any other respiratory symptoms such as sneezing or runny nose? Any combination of the following: sore throat, rhinorrhea, nasal congestion, loss of sense of smell, loss of appetite, chills, vomiting, diarrhea, headache, fatigue, and myalgia What date did your symptoms start? Date Format: MM slash DD slash YYYY Emergency Contact First Name Last Name Emergency Contact PhoneEmergency Contact - Relation to youex. spouse, partner, parent, childYour Family Doctor's nameIf you have a family Doctor, please provide their name First Name Last Name Can we send your results by text message to the number you provided?*YesNoCan we leave your results in a voicemail at the number you provided?*YesNo Please reconfirm you understand the following*Testing will NOT change the course or treatment of the illness of COVID 19. Anyone with respiratory symptoms MUST self-isolate for 10 days regardless of testing. Anyone arriving in Canada MUST self isolate for 14 days. The purpose of the assessment visit is to assess and manage any urgent respiratory symptoms as well as assess, educate and test for COVID 19 as per Provincial Guidelines. It is by all of us working together to SOCIAL distance that will keep our community safe. Thank you for doing your part #stayhome #socialdistance #missionstrong! I understandConsent Required*Patient Acknowledgement and Agreement: I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communication Services more fully described in the CMPA Consent Form. I understand and accept the risks outlined in the CMPA Consent Form, associated with the use of the Services in communications with the Physician and the Physician’s staff. I consent to the conditions and will follow the instructions outline in the CMPA Consent Form, as well as any other conditions that the Physician may impose on communications with patients using the Services. I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Physician and/or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the Physician or the Physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the Physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice. Any questions I had have been answered. I consent to receiving communications as per the CMPA CONSENT TO USE ELECTRONIC COMMUNICATIONSCommentsThis field is for validation purposes and should be left unchanged.