Name *

First Name

Last Name

Phone *

(###)

###

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I am NOT experiencing any of the following symptoms: *

- Severe difficulty breathing (e.g. struggling to breathe or speaking in single words) - Severe chest pain - Having a very hard time waking up - Feeling confused - Losing consciousness

I certify this response

I am NOT experiencing any of the following symptoms: *

- Mild to moderate shortness of breath - Inability to lie down because of difficulty breathing - Chronic health conditions that you are having difficulty managing because of difficulty breathing

I certify this response

I am NOT experiencing cold, flu or COVID-19-like symptoms, even mild ones. *

Symptoms include: fever, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches. While less common, symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discoloration of fingers or toes. Note: Average normal body temperature taken orally is about 37°C.

I certify this response

I have NOT travelled to any countries outside Canada (including the United States) within the last 14 days. *

I certify this response

I have NOT provided care or had close contact with a person with confirmed COVID-19. *

Note: This means you would have been contacted by your health authority’s public health team.

I certify this response