Covid Screening Form

Name*

Address

Phone*

Email*

Are you experiencing any of the following symptoms? Select all that apply.*

Note: Contact 911 if you are experiencing any symptoms requiring emergency care (e.g., severe difficulty breathing).

Have you had contact with any person with, or under investigation for, COVID-19 in the last 14 days?*

Have you or anyone from your immediate household travelled outside of Canada in the past 14 days (for non-essential travel)?*

In the past 10-14 days, have you been required to quarantine or isolate by your local public health authority?*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.