Full Name

Age

Email Address

Phone

Screening Questions - Select YES or NO by clicking each question below. Screening Questions - Select YES or NO by clicking each question below.

Do you have a fever or have felt hot or feverish anytime in the last two weeks? Do you have a fever or have felt hot or feverish anytime in the last two weeks?YesNo

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?YesNo

Have you experienced a recent loss of smell or taste? Have you experienced a recent loss of smell or taste?YesNo

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

Have you returned from travel within Canada from a location known affected with COVID-19? Have you returned from travel within Canada from a location known affected with COVID-19?YesNo

Are you over the age of 65? Are you over the age of 65?YesNo

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes, or any autoimmune disorder? Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes, or any autoimmune disorder?YesNo