What is your COVID-19 immunization status? *

Received all required doses MORE than 14 days ago

Partially Immunized or received all required doses LESS than 14 days ago

Unimmunized

Do you have ANY of these NEW/WORSENING signs/symptoms: (Fever/Cough/Difficulty breathing/Sore throat/Decreased taste, smell/Chills/Headaches/Fatigue/Muscle aches/Nausea/Vomiting/Diarrhea/Runny nose/Congestion)? *

Yes

No

Have you received a preliminary positive COVID-19 test result from a rapid antigen screening test? *

Yes

No

In the past 14 days, have you been in close contact with a confirmed COVID-19 case, advised to get tested by your local public health unit or by the COVID-19 app? *

Yes

No

In the past 14 days, did you return from travel outside of Canada? *

Yes

No

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Time for appointment *

Hour

Minute

Second

AM PM

I have read and agree to the terms & conditions and privacy policy *