TB Test Booking 1 Acknowledgement2 Personal Information3 Consent Consent*By checking “I agree” I am stating that I have read through this document and I agree to all of the terms stated below. I understand the procedure of tb testing and have asked all outlying questions pertaining to the test. I understand that all of my personal health information will be protected and stored in a secure location. I also understand that this information will not be shared with anyone unless medically necessary (i.e. positive tb skin test result). I understand that I have the right to withdraw my consent at any time without fear of being denied service in the future. First step TB tests are $40.00 and are to be paid on the first of two appointments Second step TB tests are $10.00 and are to be paid on the first of two appointments *EACH STEP OF THE TB SKIN TEST REQUIRE 2 APPOINTMENTS (AND INJECTION APPOINTMENT AND A READING APPOINTMENT 48 HOURS AFTER THE FIRST APPOINTMENT)* I Agree I Do Not Agree Signature* First Last (Of patient or Legal Decision-Maker)Relationship to patient:Confirmation* I have read and acknowledged the above Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemalePrefer Not to DiscloseOtherAddress* Street Address Apt # City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email Preferred Daytime Phone*Home PhoneCell PhoneFamily Doctor* Yes No Physician's NameDo you have a Health Card?* Yes No OHIP Number*Version Code*Expiry Date*TB Testing is available Thursdays (injection day) and Saturdays (reading day). NOTE: TB Testing is only available on these days. Date Format: MM slash DD slash YYYY Preferred Date For Appointment Date Format: MM slash DD slash YYYY TB Testing is only available Thursdays (injection day) and Saturdays (reading day). NOTE: TB testing is only available these two days. Emergency Contact First Last Emergency Contact RelationshipEmergency Contact PhoneTB Skin TestingTuberculin Purified Protein Derivative (5TU) Eligibility. Select option if applicable.Select One If ApplicableStudentContact with recent exposure to a known or suspected TB casePersons with HIV infectionHomeless individualsPersons entering rehabilitation or detox servicesEntry into long-term care for residents <65 years of ageTests deemed to be reasonably necessary NotesIf there is anything we should know before your appointment please let us know below.Consent* I agree to give my consent to this document.By consenting to this document, I (as the patient) confirm that this information is accurate, to the best of my knowledge. PhoneThis field is for validation purposes and should be left unchanged.