Name: | DOB: | MRN: | PCP:

Emergency Department Virtual Care Intake Form

Just like online shopping or email, virtual care has some inherent privacy and security risks that you/your child health information may be intercepted or unintentionally used. We want to make sure you understand this before we proceed. In order to improve privacy and confidentiality, you should also take steps to participate in this virtual care encounter in a private setting and should not use an employer's or someone else’s computer/device as they may be able to access your information.

If it is determined you require a physical exam or further care you may still need to be assessed in person. You should also understand that virtual care is not a substitute for attending the Emergency Department if urgent care is needed.

General Information
Fields marked with an asterisk (*) are required.
I confirm that I am 16 years or older*
The visit is for*
 
Demographics
Legal Sex*

If "Other" is selected, enter preferred language here

Emergency Contacts
Primary contact - Relationship*
Primary contact – Is legal guardian?*
Secondary contact - Relationship (optional)
Secondary contact – Is legal guardian? (optional)
Health Information
My main concern today is (check one of the following)*:

If "Other" is selected, enter main concern here

Weight Unit*
Is weight approximate or measured?*
Are your child’s immunizations up to date?*

If none, enter "None".

If none, enter "None".

Is there anyone else sick in the family?*
 
Care Team

If none, enter "None".

History
Have you been in contact with a person with known or suspected COVID-19?*
Have you traveled out of Canada in the past 2 weeks?*
Has your child ever slept in the hospital overnight?*
Has your child ever had to have an operation (surgery)?*
 
By completing and clicking on the “submit” button, you are acknowledging the transmittal, use, disclosure and sharing of personal health information through the MyChart portal prior to your virtual visit with the Emergency Department.
These documents are confidential and are for the sole use of the intended recipient. Any unauthorized use, disclosure or distribution is prohibited. If you mistakenly receive these documents please destroy and contact the sender immediately. This page was printed on Thursday 26 November 2020 at 7:17:09 PM.