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*
Is this address stable housing that you own, rent or stay in with immediate family?*

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
Were you able to contact your provider before seeking CHEO Virtual ED care?*

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?*
Ontario Health is interested to learn why you are choosing CHEO ED Virtual Care today (check one of the following)*:

If "Other" is selected, enter reason for choosing CHEO ED Virtual Care

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 Wednesday 23 June 2021 at 8:19:00 PM.