COVID-19 Patient Consent Form

Please enter your first and last name here.
Please enter your phone number.
Do you have, or have you had any flu-like symptoms in the last 14 days? This may include cough, shortness of breath or any two of: fever, headache, chills, sore throat, repeated shaking, new loss of taste or smell, muscle aches, nausea, fatigue, diarrhea or vomiting.
Are you awaiting results for a lab test for COVID-19?
Have you ever tested positive for a COIVD-19 test?
If you have tested positive in a COVID-19 test, when was it?
Have you or a family member been asked to self-isolate or self-quarantine in the last 14 days?
Have you had close contact with an individual who has tested positive for COVID-19 in the last 14 days?
Have you travelled to or from a region with high COVID-19 activity in the last 14 days?
Have you recently experienced any loss of smell or taste?
Have you left the greater Victoria area in the last 14 days?
If you have left the greater Victoria area in the last 14 days, please provide additional details.