COVID TEST FORM 123 St Anne’s Road | Winnipeg, MB, R2M 2Z1 | Canada Phone: 204.219.3660 | Fax: 204.809.4666 | Email: pharmacy @CanadaDrugstore.com Please complete the following information. This information will be used on your test result d ocumentation First Name Middle Name (optional) Last Name Terms and Conditions I confirm as follows: • I am attending Jason’s CanadaDrugstore.com (the Pharmacy) to perform Covid Rapid Antigen Test (the Test) with my own free will. • I provide consent to the Pharmacy to report m y results to public health authorities for the Test administered • If result is Positive: Will be reported to the public health authorities • If result is Negative: May be reported to public health authorities if required under the law. • I understand the Test administered by the Pharmacy is a fully private test and the costs are not covered by pu blic health • I understand the cost of the price as invoiced is non - refundable. • I understand that the Pharmacy has a policy to provide the results as quickly as possible and I will not hold the Pharmacy responsible for any financial and non - financial loss I may suffer for any delays. • I understand that the Pharmacy will not be responsible for loss or damage to the sample while being tested • I understand that I am responsible to check with my airline or my intended destination’s border control (if administering a test for travel purposes) regarding requirements including timing around which test must be carried out. • I understand the data breach risk associated with email delivery of my test results and I still provide my consent to the Pharmacy to send my results to the email address specified on this application. Signature & Date : Signature Date Name : H ealthcare # (9 digit Manitoba Health Number): D ate of Birth: (Month, Day, Year) Passport Number: Address: Gender (as indicated on passport): [ ] Male [ ] Female City, Province, Postal Code: Email Address: