Name *

First Name

Last Name

Phone *

(###)

###

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Have you tested positive for Covid-19 or have you been advised by your physician or local health department to self isolate? *

Yes

No

Do you have or have you recently (within 14-21 days) experienced any of the following symptoms? *

Please select all that apply.

Fever/Feeling hot or chills

Shortness of breath or difficulty breathing

Cough or worsening of a chronic cough

Flu-like symptoms such as upset stomach, diarrhea, headache or fatigue

Recent alteration or loss of taste or smell

Any new, unusual symptoms such as malaise or sudden onset of runny nose

I have not experienced any of these symptoms

Have you been in contact with a confirmed case of Covid-19 or anyone who has experienced any of the above symptoms? *

Yes

No

Do you have heart, lung or kidney disease, diabetes or any auto-immune disorders? *

Yes

No

Have you travelled to any Covid-19 hot spots in the last 14 days? *

Yes

No

Have you been practising social distancing? *

Yes

No