Name*

First Last

Email*

In the past 24 hours, have you experienced any of the following symptoms?*

Fever and/or chills Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup) Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Shortness of breath Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)
Decrease or loss of taste or smell Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Muscle aches/joint pain Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Extreme tiredness Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
None of the above

Not due to previously known chronic conditions diagnosed by a health care professional

In the last 10 days, have you been identified as a ‘close contact’ of someone who currently has COVID-19?*

Yes
No

If public health has advised you that you do not need to self-isolate, select ‘no’.

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?*

Yes
No

If you already went for a PCR test and got a negative result, select ‘no’.

Is anyone you currently live with experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*

Yes
No

In the past 14 days, have you or anyone in your household been advised by Public Health or a healthcare provider to self-isolate for any reason?*

Yes
No

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?*

Yes
No

If you have since tested negative on a lab-based PCR test, select ‘no’.

In the last 14 days, have you travelled outside of Canada?*

Yes
No

If exempt from federal requirements (for example, you are fully vaccinated and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select ‘no’.

I declare that the information I have provided is accurate & complete*

Yes

Covid-19 Screening

Contact Info

Hours of Operation

After hours Emergency