Name *

First Name

Last Name

Are you experiencing any of the following symptoms? *

Fever

Cough

Shortness of Breath

Running Nose

Sore Throat

No Symptoms

Have you or any of your family members, been diagnosed with COVID- 19 within the last 14 days ? *

Yes

No

Have you been in contact with anyone who has been diagnosed with COVID 19? *

Yes

No

Have you travelled outside of Canada in the last 14 days? *

Yes

No

Have you been in contact with anyone who has travelled outside of Canada in the last 14 days? *

Yes

No