TB Test Booking

1 Acknowledgement

2 Personal Information

3 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.
- 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*
Address*
Street Address Apt # City Province Postal Code

Email

Preferred Daytime Phone*
Home Phone
Cell Phone
Family Doctor*
Yes
No
Physician's Name
Do 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 Relationship
Emergency Contact Phone
TB Skin Testing
Tuberculin Purified Protein Derivative (5TU) Eligibility. Select option if applicable.

Notes
If 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.
Comments
This field is for validation purposes and should be left unchanged.

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