Name *

First Name

Last Name

Phone

(###)

###

####

Do you have any of the following symptoms: Fever, feverish, new or existing cough, and/or difficulty breathing *

No, no symptoms whatsoever

Yes, some or all symptoms

Have you had any contact with an individual with a confirmed or probable COVID-19 case? *

No

Yes

Have you had close contact with a person with acute respiratory illness who has been outside of Canada in the last 14 days? *

No

Yes

Have you traveled internationally within the last 14 days? (outisde Canada) *

No

Yes

No, but I traveled outside of the Province within Canada

The information that I (the client) provided is true and correct. *

I agree