Whole Health Pharmacy Partners

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Home
First Line Health Clinic
About Us
Services
Medical Supplies
Available Vendor
Resources

Services

WE OFFER

Covid Vaccinations

Covid Vaccines And Flu Shots Booking

Functional Medicine

Specialty Compounding

Blister Packaging

Methadone Dispensing

Pharmacogenomic Testing

NAAT Test with PCR Testing

Functional Medicine
Specialty Compounding
Blister Packaging
Methadone Dispensing
Other Services
Service Areas

Pre-Exposure Prophylaxis

Smoking Cessation

Corona Virus

Medical Cannabis Consultations

Book Here

COVID-19 Testing Assessment Form

Date of Travel

First Name

Last Name

Address

City & Postal Code

Email

Phone

Birth Date

Health Card Number including the 2 letters (enter passport # if no Health Card available)

Gender

Female Male

Do you or anyone in your household have any of the following symptoms

Fever Cough Shortness of Breath Difficulty in Breathing Sore Throat Chills Nose Congestion Runny Nose Feeling Unwell Vomiting Loss of Appetite Headaches Loss of Taste Eye Infection/Pink Eye None of the Above

In the last 14 days, did you return from travel outside of Canada?

Yes No

In the past 14 days, have been identified as close contact of someone who is confirmed as COVID 19. A close contact is defined as a person: 1) who provided care for the patient, including healthcare workers, family members or other caregivers. or 2) Who had other similar close physical contact or 3) Who lived with otherwise had close prolonged contact with a probable or confirmed case while the case was ill

Yes No

Have you been advised to get tested for COVID-19 by your local public Health unit due to exposure to a confirmed case or as part of an outbreak investigation?

Yes No

Are you member of one of the listed groups?

Resident or worker in long term care home (may need investigation under) Visitor to a long-term care home Resident or worker in homeless shelter Farm worker Resident or worker in other congregate settings (shelters, group homes, supportive housing) International student that has passed your 14-day quarantine period Resident or worker in retirement home Self-identify as indigenous None of the above

Have you received a preliminary positive COVID-19 test result from a rapid antigen screening test?

Yes No

Have you been advised to get tested for COVID-19 through an exposure notification through COVID-19 App?

Yes No

Are you over the age of 70 and experiencing any of the following : delirium, unexplained or increased number of falls, acute functional decline, worsening chronic conditions?

Yes No

Do you require a COVID-19 test for International travel clearance?

Yes No

Date of Signature

Signature

320 College Street North

Durham, ON N0G 1R0

519-369-5330

CUSTOMER SUPPORT

Send Email

wholehealthpharmacydurham@gmail.com

Home
About Us
Services
Medical Supplies
Available Vendor
Resources
Contact Us

Home
About Us
Services
Medical Supplies
Available Vendor
Resources
Contact Us

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