Customer COVID-19 Screening

  • MM slash DD slash YYYY
  • Do you have any new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. Fever or chills, difficulty breathing or shortness of breath, cough, sore throat, runny nose, decrease or loss of smell, stomach illness, headache?
  • Have you had close contact with a confirmed or probable case of COVID-19?
  • Has a doctor, health care provider, or public health unit told you or someone in your household that they should currently be isolating (staying at home)?
  • This field is for validation purposes and should be left unchanged.