Diagnostic Testing Intake Form

First Name *

Last Name *

Email *

Phone Number *

Birthday *

RAMQ #

Gender *

Please answer this question.

[If Applicable] Are you prone to fainting during blood tests? *

NoYesNo

[If applicable] Do you have a fear of needles or blood tests? *

NoYesNo

I hereby authorise a sample be taken off my person for the purpose of undergoing screening for a range of tests as prescribed by my physician or another qualified healthcare provider. *

NoYesNo

I have verified that my doctor’s requisition is legible. If certain tests are not legible, I hereby give GTR Santé permission to omit the test or to use their best efforts in selecting the appropriate test. I understand that if the wrong test is selected due to illegible writing, there may be a cost for re-testing if another service is required. *

NoYesNo

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Signature :

Diagnostic Testing Intake Form

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