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See the promotion! Valid from November 21st to December 4th, 2022

Covid-19 Form

All fields identified by an asterisk (*) are mandatory.

Personnal informations

Questions

  1. Have you had any symptoms of COVID-19 (cough, fever, shortness of breath, change in taste or smell) in the past 14 days? *

  2. Have you been exposed to a person infected with COVID-19 in the past 14 days? *

  3. Are you waiting for a test result for COVID-19? *

  4. Have you traveled outside the country in the last 14 days? *

  5. Have you tested positive for COVID-19 in the last 14 days? *

  6. Have you had a voluntary isolation order issued by a public health authority within the last 14 days? *

  7. Does anyone in your household have one or more symptoms of COVID-19 (cough, fever, shortness of breath, change in taste or smell) and/or is waiting for test results after experiencing symptoms? *

  8. In the past 10 days, have you tested positive on a rapid home test? *

  9. Do you live with a confirmed COVID-19 positive case? *

  10. Do you live with a suspected case or a person in isolation following close contact with a variant case? *

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