COVID-19 Case Investigation & Symptom Form

This investigation tool helps complete your Covid-19 registration and swabbing process.

Let’s all look out for each other by knowing our status, trying not to infect others, and reserving care for those in need.

COVID-19 Case Investigation & Symptom Form

You’ll answer a few questions about symptoms, travel, and contact you’ve had with others.

Your answers will not be shared with anyone without your permission.

By using this tool, you agree to its terms and that Bay Street Medical will not be liable for any harm relating to your use.

Recommendations provided by this tool do not constitute medical advice and should not be used to diagnose or treat medical conditions.

Enter your name, address and contact information:

Full Name (First, Middle & Last) as on Government issued Identification Card (required)

Please enter your full name.

Email Address (required)

Please enter a valid email address.

Phone Number (required)

Please enter a valid 10-digit mobile number.

Mobile Number

Date of Birth (required)

Please select your Date of Birth.

Gender (required)

Please select your gender.

Street Address (required)

Please enter a maximum of 35 characters.

Apt, Suite, Building Number (required)

Please enter an Apt, Suite, Building Number.

Island

Country/Region (required)

Please enter your Country/Region.

Government ID Type (required)

Please select Government ID Type.

Government issued Identification Number (required)

Please enter your Identification Number.

Passport / Driver's License / National Insurance Number

Nationality

Upload (NIB / Drivers License / Passport) (required)

Please upload your photo identification.

Upload Government issued Identification Card that shows your "Photo", "Full Name" and "Date of Birth"

Occupation

Place of employment

Reason for testing (required)

Please select an option.

Which COVID-19 test do you want to take? (required)

Please select an option.

Do you have any COVID-19 symptoms? (required)

Please select an option.

Are you fully vaccinated (2 weeks have passed after second shot)? (required)

Please select an option.

Date of Vaccination (required)

Please select your Date of Vaccination.

Have you recently started experiencing any of these symptoms?

Select all that apply.

Date of onset of illness (required)

Please select most recent date of onset of illness.

In the last 14 days, have you traveled domestically?

In the last 14 days, have you traveled internationally?

In the last 14 days, was there close contact with a known COVID‑19 positive case?

Close contact is defined as contact for more than 15 minutes and within less than 6 feet distance.

Disposition - Is/was the patient hospitalized?

Would You Like To Share These Answers?

Completed

ID	Patient Name	Email Address	Phone Number	Share Details	Progress	Date Created	Actions

COVID-19 Questionnaire

COVID-19 Case Investigation & Symptom Form

COVID-19 Case Investigation & Symptom Form

Enter your name, address and contact information:

Have you recently started experiencing any of these symptoms?

In the last 14 days, have you traveled domestically?

In the last 14 days, have you traveled internationally?

In the last 14 days, was there close contact with a known COVID‑19 positive case?

Disposition - Is/was the patient hospitalized?

Would You Like To Share These Answers?

Your Responses

COVID-19 Questionnaire

COVID-19 Case Investigation & Symptom Form

COVID-19 Case Investigation & Symptom Form

Enter your name, address and contact information:

Have you recently started experiencing any of these symptoms?

In the last 14 days, have you traveled domestically?

In the last 14 days, have you traveled internationally?

In the last 14 days, was there close contact with a known COVID‑19 positive case?

Disposition - Is/was the patient hospitalized?

Would You Like To Share These Answers?

What Will Be Shared

Disclaimer

Would you like to share the test results with your employer/organization?

Your Responses