Name
*
First Name
Last Name
Review of Symptoms
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Do you, or anyone in your household, currently experiencing any of the following symptoms? Check ANY and ALL that apply.
Contact with Anyone with Symptoms
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Have you, or has anyone in your household, been in close contact (less than 6 feet without PPE) with anyone who has experienced any of the above symptoms within the last 14 days?
Contact with Anyone Suspect
*
Have you, or has anyone in your household, been in close contact with a suspected or confirmed case of COVID-19 within the last 14 days?
Travel History
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Have you, or has anyone in your household, been in close contact (less than 6 feet without PPE) with a person who has travelled outside of Ontario within the last 14 days?
Outbreak
*
Have you, or has anyone in your household, visited a facility that has had a COVID-19 outbreak within the last 14 days?
Social Gathering
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Have you, or has anyone in your household, attended a gathering of 10 or more people within the last 14 days?
Declaration
By submitting this form, I confirm that the information above is correct to the best of my knowledge. I further understand that I may need to contact my doctor, Telehealth or Public Health and I may be referred for COVID-19 testing.
