Fillable Patient Information Last Name, First Name Health Card (City of Oakland)

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Patient Information Last Name, First Name Health Card (City of Oakland)

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Adapted from Ministry of Health. https://covid-19.ontario.ca/self-assessment/ Updated: September 3, 2021
Asymptomatic COVID-19 Testing – Documentation Checklist (Screening)
To be reviewed and signed by the patient / caregiver:
For Antigen Rapid Test
By signing below, I acknowledge and confirm that:
• I have read and understood the information contained in the
Asymptomatic Panbio™ COVID-19 Rapid Antigen Screening – What
you should know pamphlet
• The Rapid Antigen Test is for screening purposes only and
cannot be used to diagnose a COVID-19 infection
• If I receive a positive antigen screening test result, I must
arrange a PCR COVID-19 test within 24 hours to confirm a
COVID-19 diagnosis
• It is possible that I have a COVID-19 infection even if I receive a
negative antigen screening test result
• Walmart is not responsible for my reliance on the antigen
screening test results
• I am providing consent to the pharmacist on-duty to provide the
COVID-19 Asymptomatic Assessment and Specimen Collection
and all my questions about the Rapid Antigen Screening test
have been answered by the pharmacy staff
For PCR Swab Test
By signing below, I acknowledge and confirm that:
• I have read and understood the information contained in the
COVID-19 Asymptomatic Testing – What you should know
pamphlet
• If I receive a positive PCR COVID-19 test result, I must self-
isolate for 14 days following the day I was tested if I do not
have any symptoms. If I develop any symptoms, I must self-
isolate for 14 days following the day my symptoms started
• I am providing consent to the pharmacist on-duty to provide
the COVID-19 Asymptomatic Assessment and Specimen
Collection and all my questions about the PCR swab test have
been answered by the pharmacy staff
Patient / Caregiver Signature Date
Patient Information
Last Name, First Name Health Card Available? Health Card No.
☐
Y
☐ N 79999 999 93
Date of Birth (mm/dd/yyyy)
Investigational / Outbreak No.
Patient Address
Address City / Town Province
ON
Email Address
Caregiver / Patient’s Agent Information (if applicable)
Last Name, First Name
Notes
Telephone Number Email Address
Primary Care Provider (if applicable)
Last Name, First Name
Designation
License Number
Email Address
Assessment Conducted At
Pharmacy Name
WALMART PHARMACY #
Address
City / Town
Province
ON
Postal Code
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Patient Information Last Name, First Name Health Card (City of Oakland)

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Completed 11 January 2022

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