Name *

First Name

Last Name

Phone

(###)

###

####

Are you experiencing any of the following symptoms?

Fever higher than 38°C Chills Cough Loss of sense of smell or taste Difficulty breathing

Yes

No

Are you experiencing any of the following?

Sore throat Loss of appetite Extreme fatigue or tiredness Headache Body aches Nausea or vomiting Diarrhea

Yes

No

Have you returned from travel outside Canada in the last 14 days?

Yes

No

Have you been notified by public health that you are a close contact of a person confirmed to have COVID-19?

Yes

No