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.

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

Please enter an Apt, Suite, Building.

Island

Country/Region

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.

Other - Reason for testing (required)

Please enter other reason for testing.

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

Please select an option.

COVID-19 test result priority (Rush / No Rush) (required)

Please select an option.

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

Please select an option.

Select all that apply.

Date of onset of illness (required)

Please select most recent date of onset of illness.

Where was you most recent travel? (required)

Please fill the above mandatory field.

Date of most recent travel (required)

Please select most recent date of travel.

Where was you most recent travel? (required)

Please fill the above mandatory field.

Date of most recent travel (required)

Please select most recent date of travel.

Date of Exposure (required)

Please select date of exposure.

Date of Death (required)

Please select date of death.

Date of Hospitalization (required)

Please select date of hospitalization.

Completed {{ completedDate | date: "MMMM d, y, h:mm a" }}

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

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