Name*

First Last

Email*

Are you a current patient?

Yes
No

Do you have a fever or have felt hot or feverish anytime in the last 10 days?*

Yes
No

Do you have any of the following symptoms: new cough or worsening cough? New shortness of breath or worsening shortness of breath? Difficulty breathing? Sore throat or painful swallowing? Flu-like symptoms? Runny nose?*

Yes
No

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of determined risk for COVID-19?*

Yes
No

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

Yes
No

Have you lost your sense of smell?*

Yes
No

Have you returned from travel within Canada from a location known affected with COVID-19 in the last 14 days?*

Yes
No

Is your workplace considered high risk? (e.g. routine close contact with many people)*

Yes
No