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COVID-19 Screening Form
We take every precaution for your safety!
3
COVID-19 SCREENING FORM
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Name
*
First
Last
Phone
*
Email
*
Are you exhibiting any of the following symptoms?
*
Fever or chills
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
None of the above
Have you traveled outside of Canada in the past 14 days?
*
Yes
No
Signature
*
Clear Signature
Date
*
Submit
