First Name

Last Name

Address Line #1

Address Line #2

City

Province

Do you or anyone in your household have any of the following new or worsening symptoms or signs? Do you or anyone in your household have any of the following new or worsening symptoms or signs? Fever or chills Difficulty breathing or shortness of breath Cough Sore throat or trouble swallowing Runny/stuffy nose or nasal congestion Decrease or loss of smell or taste Nausea, vomiting, diarrhea, abdominal pain Felling unwell or extreme tiredness Sore muscles None of the Above

Have you or anyone in your household travelled outside of Canada in the last 14 days? Have you or anyone in your household travelled outside of Canada in the last 14 days? Yes No

Have you or anyone in your household been in contact with a confirmed or probable case of COVID-19? Have you or anyone in your household been in contact with a confirmed or probable case of COVID-19? Yes No