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Quinte Health Care
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This webform is ONLY for use to pre-register for the Community Assessment Centres located in Picton.  Please click here to pre-register for Belleville, Trenton, and Bancroft. Complete all required fields in the COVID-19 Community Assessment Centre Pre-registration form in order to submit the form.  Within one business day you will be provided with instructions for attending the Community Assessment Centre in Picton.  

Quinte Health Care has made an exception to allow the use of unencrypted email for the purpose of preregistering during the declared emergency.  In order for QHC to use unencrypted email, we must obtain the consent of the patient for this purpose.  If you do not consent, please pre-register by phone at 613-813-6864.  

Do you consent, understanding that unencrypted email carries an inherent risk of disclosure to third parties, to the use of email for the purpose of sending confirmation of your Preregistration Status for your Community Assessment Centre visit in Picton?*
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Note: Please enter your name as it appears on your health card.
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Birthday*
  
Gender*
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Are you experiencing any symptoms? (Please ensure you have completed the self-assessment and meet the latest provincial guidelines for testing. Visit the COVID-19 page of our website – www.qhc.on.ca for more information.)*
Please select any symptoms you are experiencing.
Were you exposed to an individual with a probable or confirmed case of COVID-19? *
Have you traveled out of Ontario or Canada in the last 14 days? *
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IMPORTANT NOTE: PLEASE FILL OUT SEPARATE FORM FOR EVERYONE REQUIRING TESTING.
What is your preferred date for testing? *