Viewing Appointment Name(Required) First Last Phone(Required)Email(Required) Do you have any of the following new or worsening symptoms or signs?Fever or Chills(Required) Yes No Cough(Required) Yes No Trouble Breathing(Required) Yes No Sore Throat or Trouble Swallowing(Required) Yes No Runny or Stuffy Nose(Required) Yes No Decrease of Loss of taste or smell(Required) Yes No Nausea, Vomiting, or Diarrhea(Required) Yes No Pink Eye(Required) Yes No Headache(Required) Yes No Very Tired, Sore Muscles or Joints(Required) Yes No Does anyone in your household have one or more of the above symptoms and/or are waiting for test results experiencing symptoms?(Required) Yes No Have you been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate?(Required) Yes No In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?(Required) Yes No In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?(Required) Yes No Have you been fully vaccinated?(Required) Yes No
