COVID-19 Customer Screening

First Name

Last Name

Email

Address

City

Province

Postal/Zip Code

Primary Phone

Do you have new or worsening symptoms or signs of fever or chills?

Do you have new or worsening symptoms or signs of a cough?

Do you have new or worsening symptoms or signs of runny nose/stuffy nose or nasal congestion?

Do you have new or worsening symptoms or signs of nausea, vomiting, diarrhea, abdominal pain?

Have you travelled outside of Canada in the past 14 days?

Do you have new or worsening symptoms or signs of difficulty breathing or shortness of breath?

Do you have new or worsening symptoms or signs of sore throat, trouble swallowing?

Do you have new or worsening symptoms or signs of decrease or loss of smell or taste?

Do you have new or worsening symptoms or signs of not feeling well, extreme tiredness, sore muscles?

Have you had close contact with a confirmed or probable case of COVID-19?

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