*all fields are required Name: Email: Best Contact Number: Do you have a fever (37.5 degrees Celsius or higher) or have felt hot or feverish anytime in the last two weeks? YesNo Do you have a dry cough? YesNo Do you have shortness of breath? YesNo Do you have difficulty breathing? YesNo Do you have a runny nose? YesNo Are you sneezing? YesNo Do you have a sore throat? YesNo Have you experienced a recent loss of smell or taste? YesNo Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? YesNo Is your workplace considered high risk? YesNo
