Questionnaire

Order form

Payment

Question 1/9

Please select the province you will be completing testing in:

Question 2/9

Have you received a COVID 19 positive PCR test result in the past 90 days?

Question 3/9

Are you experiencing any of the following symptoms: fever, new onset of cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, decrease of loss of sense of taste or smell, chills, headaches, unexplained fatigue/malaise/muscle aches (myalgias), nausea/vomiting, diarrhea, abdominal pain, pink eye (conjunctivitis), runny nose or nasal congestion without other known cause?

Question 4/9

In the past 14 days, did you return from travel outside of Canada AND Been advised to quarantine per the federal quarantine requirements?

Question 5/9

In the past 14 days, have you been identified as a close contact* of someone who is confirmed as having COVID-19?

A close contacts is defined as:

  • A person who provided care for the patient, including healthcare workers, workers,
    family members or other caregivers, or
  • Who had other similar close physical contact or
  • Who lived with or otherwise had close, prolonged contact with a probable or confirmed case while the case was ill

Question 6/9

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Question 7/9

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test, select "No"

Question 8/9

Are you over the age of 70 and experiencing any of the following: delirium, unexplained or increased number of falls, acute functional decline, worsening chronic conditions?

Question 9/9

The passenger and/or their representative confirm that these responses are true, and if untrue, they will be responsible for any harm that results