PCR Tests for Travelers -

PCR Tests for Travelers

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WE ARE UNABLE TO TEST SYMPTOMATIC INDIVIDUALS. IF YOU ARE EXPERIENCING ANY COVID-19 SYMPTOMS PLEASE
CONTACT YOUR LOCAL PUBLIC HEALTH UNIT.

As per the Ministry of Health COVID-19 Testing Guidelines, Derry Health and Wellness Center (DHWC) is only allowed to offer testing for asymptomatic patients who do not have any potential exposure to COVID-19. By accepting this, you acknowledge the following:

1) I have not been in contact with any person who has symptoms or tested positive for COVID-19 in the last 14 days.

2) I do not currently have any of the COVID-19 symptoms, nor have I experienced any within the last 14 days.

3) I have not tested positive for COVID-19 in the last 14 days.
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- Ministry of Health COVID-19 Testing Guidelines
Services (Required)
Select Test Date and Time

Name*
First Last
Email*
Phone*
Date of Birth*
Gender*
Health Card #*
Passport Number*
Date of flight*
Address*
By clicking “ACCEPT” below, I fully agree to the following:

1. I agree to abide by Derry Health & Wellness Center (DHWC) cancellation and rescheduling policy in respect to appointments. If I cancel or reschedule with less than FORTY EIGHT (48) HOURS’ notice, I agree to pay an administrative fee to DHWC of FIFTY CANADIAN DOLLARS ($50 CAD). If I cancel with less than TWENTY FOUR (24) HOURS’ notice, or If I am late than TEN (10) MINUTES to my appointment, I understand and agree that it will be considered as I have missed my appointment and I will forfeit my fee for appointment.

2. I confirm that I am undergoing this private Covid-19 test (the “Test”) DHWC on an voluntary basis and that I have no symptoms of COVID-19.

3. I understand that I will be releasing certain private information about myself (including the information in this form and any other medical information I disclose to DHWC and its staff during the Test), and that the results of the Test (the “Results”) are also considered part of my private information (altogether the “Private Information”). The Private Information may be transmitted via electronic means, including but not limited to email, texting, or via certain mobile applications

4. I hereby authorize the release of my Private Information (a) to me via my email address or by text message to my phone number and (b) to those entities managing approved mobile applications and related software for the handling and dissemination of the Private Information through electronic means, as noted above and (c) to relevant public health authorities on a “need-to-know” basis, having regard to the infectious nature of Covid-19 as a serious communicable disease and the current pandemic situation in and throughout Canada and the world. I also acknowledge that the Results may also be anonymously pooled with the results of other persons in order to determine community prevalence or other statistics related to COVID-19, and these results may be reported or published.

5. I authorize DHWC, its staff and laboratory partners to conduct and coordinate specimen collection, swab storage, transportation, testing, and reporting for COVID-19 via a bilateral anterior nasal or other alternative swab (altogether the “Services”). As with any biological test, I understand that there is the potential of false positive or false negative results. I hereby recognize that DHWC is relying on third party efforts, data and laboratories and agree to hold DHWC harmless and clear of any liability if Test results are not accurate. In particular, I hereby release and hold DHWC harmless from all liabilities in the event that the Test yield results that do not meet the entry requirements of any country or if Test results are not accepted by departing or arrival airports or authorities for any reason.

6. I understand that Test turnaround times will be met on a best-efforts basis, but that no specific time frame has been guaranteed.

7. If my Test is reported as positive for COVID-19, I may be contacted directly by DHWC and by the appropriate public health authority and may be asked to attend a public health or other location for additional testing. I also acknowledge that a positive Test result means that I must self-isolate and comply with all directives provided by relevant public health authorities.

8.I understand that neither DHWC nor its laboratory partners are acting as my medical service provider or medical practitioner. This testing does not replace treatment by my medical service provider or medical practitioner, and I assume complete and full responsibility to take appropriate action with regards to the Test Results. I agree that I will seek medical advice, care and treatment from my medical provider and local health authority if I have questions or concerns.

9. I hereby consent for myself, my heirs, executors, administrators, assignees and/or personal representatives. I knowingly and voluntarily agree to this Test and waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in this Test, and do hereby release and forever discharge DHWC, its laboratory partners, and their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assignees, for any physical or psychological injury or loss, including but not limited to cancellation or interruption of my planned travel, illness, paralysis, death, economical or emotional loss, that I may suffer as a direct result of my participation in this activity, including traveling to and from any location related to this activity. Should I require medical care or treatment or if I am denied entry to any destination, I agree to be financially responsible for any costs incurred for such treatment. I agree to indemnify and hold harmless DHWC and their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assignees against any and all claims, suits, or actions of any kind whatsoever for any fees, costs, liability, damages, compensation, or otherwise brought by me or anyone on my behalf, including legal fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.

10. I, the undersigned, hereby confirm I am at least of the age of majority in the jurisdiction that I am principally resident in (or alternatively, I am the parent / legal guardian of the person submitting to the Test) and have been informed about the Test purpose, procedures, possible benefits and risks, and the collection and disclosure of my Private Information associated therewith.
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- I have read and agree to the terms above *
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- I confirm that I do not have any symptoms of COVID-19, have not been in contact with a known positive COVID-19 case in the last 14 days, and have not tested positive for COVID-19 by rapid antigen test in the last 10 days.
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