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First & Last Name


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

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

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Fever or chills*

Difficulty breathing or shortness of breath*

Cough/Runny nose/stuffy nose or nasal congestion*

Sore throat, trouble swallowing*

Nausea, vomiting, diarrhea, abdominal pain*

Not feeling well, extreme tiredness, sore muscles*

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