[/fusion_title][fusion_code]
Your name:
Your email (so you have a copy to show the receptionist – if required)
Do you have any of the following:
Fever? YesNo
Cough? YesNo
Difficulty breathing? YesNo
Sore throat? YesNo
Runny nose? YesNo
Loss of taste or smell? YesNo
Not feeling well? YesNo
Nausea, vomiting or diarrhea? YesNo
Within the last 14 days have you travelled outside of Canada and been told by government officials to quarantine? YesNo
Within the last 14 days have you travelled outside Canada? YesNo
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