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COVID-19 Assessment

This webform is ONLY for use to pre-register for the Community Assessment Center located in Perth and Smiths Falls. Complete all required fields in the COVID-19 Community Assessment Centre Pre-registration form to submit the form. Within 24 hours you will be provided with a date and instructions for attending the assessment appointment.

Perth and Smiths Falls District Hospital has made an exception has made an exception to allow the use of unencrypted email for preregistering during the declared emergency. In order for PSFDH to use unencrypted email, we must obtain the consent of the patient for this purpose. If you do not consent, please pre-register by phone at 613 283-2330 ex 1401. 

 

Covid Assessment Clinic Registration

Do you consent, understanding that unencrypted email carries an inherent risk of disclosure to third parties, to the use of email for the purpose of sending confirmation of your Preregistration Status for your COVID-19 Assessment Center visit?”:
Do you consent, understanding that unencrypted email carries an inherent risk of disclosure to third parties, to the use of email for the purpose of sending confirmation of your Preregistration Status for your COVID-19 Assessment Center visit?”

Note: Please enter your name as it appears on your health card.

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Gender:
Gender

Are you experiencing any symptoms? (Please note as of Sept. 24, testing guidelines changed to reduce testing of individuals not experiencing symptoms. We ask that you please refrain from getting tested unless you meet the criteria listed on the COVID-19 page of our website – www.psfdh.on.ca):
Are you experiencing any symptoms? (Please note as of Sept. 24, testing guidelines changed to reduce testing of individuals not experiencing symptoms. We ask that you please refrain from getting tested unless you meet the criteria listed on the COVID-19 page of our website – www.psfdh.on.ca)
Please select any symptoms you are experiencing. :
Please select any symptoms you are experiencing.





Were you exposed to an individual with a probable or confirmed case of COVID-19?:
Were you exposed to an individual with a probable or confirmed case of COVID-19?
Have you traveled out of Ontario or Canada in the last 21 days? :
Have you traveled out of Ontario or Canada in the last 21 days?
 

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