Health Screening – Kingsway

* First Name

* Last Name

* Phone

* Email

* Temperature

Have you or anyone in your household exhibited any of the COVID-19 symptoms in the last 14 days? For example: fever, cough, runny nose, sore throat, shortness of breath, etc?
YESNO

Have you or anyone in your household travelled outside of Canada within the last 14 days?
YESNO

Have you knowingly been in close contact with someone who has tested positive for COVID-19 and/ or has the COVID-19 symptoms?
YESNO

I hereby confirm that my answers to the above questions are true to the best of my knowledge and I understand that providing false information is a criminal offence.