安捷 Mississauga

姓氏（Last Name，请用英文填写） *
名字（First Name，请用英文填写） *
Passport Number （护照号码） *
Gender (性别） *

Male （男） Female （女） Other （其它）
Date of Birth （生日） *

Year Month Day
Date
Phone Number （电话） *
Please enter a valid phone number.
Email （电子邮件） *
example@example.com
Address （地址） *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact （紧急联系人）

名字姓氏
Emergency Contact Phone Number 紧急联系人电话
Please enter a valid phone number.

Screening Questions

Please call 911 if you are experiencing severe difficulty in breathing, severe chest pain, change in the level of consciousness, or any other significant discomfort. （如果身体严重不适请联系911）

Our rapid COVID-19 screening for travelers is approved for ONLY asymptomatic travelers by Health Canada. You must go to a public testing site if you have the following symptoms （我们只检测无症状客人。有以下症状请联系公共卫生部门）:

Chills or significant tiredness/fatigue/lack of energy （身体发抖/疲惫）

Fever of 37.8°C (100°F) or higher （发烧体温37度8以上）

Sore throat, cough, barking cough, or recent worsening of wheezing （嗓子痛，咳嗽，喘气）

Shortness of breath or difficulty/pain swallowing （呼吸困难/吞咽困难）

Decrease or loss of taste or smell （味觉和嗅觉下降）

Recent onset runny or stuffy/congested nose （流鼻涕/鼻塞）

Pink eye （眼睛红）

Digestive issues like nausea/vomiting, diarrhea, stomach pain （呕吐/恶心，腹泻，胃痛）

Recent onset headache or muscle aches （头痛，肌肉痛）

Recent contact with patient confirmed or suspected of having COVID-19 （近期与新冠病人有接触）
I do not have any of the symptoms or conditions described above. （无上述症状） *

Confirm (确认）

Consent (检测同意书）

We offer COVID-19 screening PCR, antigen, IgM/IgG, serology tests for screening purposes only. While significant efforts have been made to deliver your test results back as fast as possible, we cannot guarantee that your results will be delivered within a specific timeline.

I hereby acknowledge that:

As with all laboratory testing, COVID-19 and related tests, have inherent limitations, such as a risk of false positives/negatives.
We make no representation or warranty of any kind related to the applicability of any COVID-19 and related tests for a particular purpose and/or delivering results within a specific timeline.

We shall, under no circumstances, be liable for any damages I may incur (including, but not limited to, any damages related to missed flights or other travel related costs, or any indirect, incidental, consequential, punitive, special or exemplary damages) arising from COVID-19 and related test results and/or reports that we perform and/or fail to perform for any reasons.

I agree to receive the results of my test at the email address that I have provided. I acknowledge that email may not be a secure means of communication.

I confirm that the email address provided by me has been accurately recorded. If the email address that I have provided does not belong to me, I authorize the owner of the email address to receive my test result by email on my behalf. I understand that the email address I have provided must be validated (in accordance with instructions provided to me) in order to receive my test results by email.
Confirm (确认） *

Confirm（确认）
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

安捷检测预约 Mississauga