Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Fill out the ‘Submitter’ section by providing the health card number, name, address, city and province, postal code, and medical record number. Ensure all fields are completed as this is mandatory.
3. In the ‘Patient Information’ section, input the last name, first name, phone number, and postal code of the patient. Make sure to include the fax number if available.
4. Complete the ‘Travel History’ section by noting the lab or clinic name, travel destination, and travel dates. Include your telephone and fax numbers as well.
5. In the ‘Exposure History’ section, specify if there was an exposure to a probable or confirmed case. Provide additional exposure details if applicable.
6. For the ‘Test(s) Requested’ section, indicate the desired tests by checking the appropriate boxes. This includes COVID-19 virus testing, and specify if confirmation or clearance is required.
7. In the ‘Specimen Type’ section, check all applicable specimen types and provide the specimen collection date. If possible, indicate the preferred types (NPS in UTM, throat swab, etc.).
8. Complete the ‘Clinical Information’ section by noting the date of symptom onset as well as any symptoms experienced, such as fever or cough.
9. In the ‘Patient Setting / Population’ section, select the applicable assessment type and indicate if the patient belongs to any specific group.
10. Finally, answer whether the patient will be hospitalized and provide details if necessary.
11. Review all the completed information for accuracy. Save changes, and when ready, download, print, or share the form as needed.

Complete your documents online today to ensure timely processing.