TB Test | Quinte Travel Health Clinic

I have read and agree to the terms above.(Required)

Yes

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Birth date(Required)

Gender

Purpose for TB screening(Required)

Education ($25.00)

Medically Indicated ($25.00)

Employment ($50.00)

Volunteer ($50.00)

Admission as a Resident to a Long-Term Care or Retirement Facility

Please bring documentation to support request for medical/education purposes TB testing.

Tuberculin Skin Test Consent

Tuberculin Skin Testing (TST) is administered as an aid in the detection of infection with M. tuberculosis.

If YES to any of the following questions, please contact our office at 613-966-5486 and do not proceed with online booking.

Possible Side Effects:

Side effects are rare. Vesiculation, ulceration or necrosis may appear at the test sit in highly sensitive persons. There have been reports of rare systemic allergic reactions manifested by skin rash within 24 hours. Should these side effects occur, seek immediate medical attention.

Please contact our office at 613-966-5486 and do not proceed with online booking.

Have you had a previous severe reaction (e.g., anaphylaxis, blistering, necrosis or ulceration) to a TB skin test?(Required)

Yes

Have you had active TB or treatment in the past?(Required)

Yes

Have you ever had a positive reaction to a previous TB skin test which was read by a knowledgeable healthcare worker and documented?(Required)

Yes

Within the past month, have you contracted any of the following illnesses: measles, mumps, chicken pox, infectious mononucleosis, typhoid, brucellosis, influenza or whooping cough (pertussis)?(Required)

Yes

Within the past month, have you had immunization with a live viral vaccine (e.g., MMR -measles/mumps/rubella, varicella vaccines)?(Required)

Yes

Appointment Fee

I have read and understood all information provided to me and my questions have been answered to my satisfaction.

I authorize a nurse from Walsh & Associates Occupational Health Services Ltd. to administer TST.

I agree to seek immediate medical attention, if I should develop any health problems following the administration of the TST (such as difficulty breathing, facial swelling, high fever, muscular weakness or hives).

I will return to the Occupational Health Services on the dates provided to me by the Nurse for reading of the TST.*

(48 hours later on Thursday at the same time as was booked Tuesday)

I have completed the form and agree to the above terms(Required)

Yes

You have answered YES to one or more of the questions. Please contact our office at 613-966-5486 and do not proceed with online booking.

Tuberculin Skin Test (Belleville Location Only)

YOUR APPOINTMENT IS NOT CONFIRMED UNTIL PAYMENT IS RECEIVED.

TERMS AND CONDITIONS

VACCINATIONS

HEALTH PRECAUTIONS

PAPERWORK

LOCATION

Tuberculin Skin Test Consent