COVID-19 Customer Screening
Your personal details
First Name*
Last Name*
Email*
Address
City
Province
Postal/Zip Code
Primary Phone*
COVID-19 Screening
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?*
What Department or Sales Executive Are You Here To See?*
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