COVID-19 Screening Form

Please fill out this COVID-19 questionnaire the day of your dinner reservation.

The result is no longer valid if your situation changes during the day (for example, you start experiencing symptoms).

The people with you should also take this screening. You can take it on their behalf if they cannot do it themselves.

Screening Form Submission Valid On April 26, 2024

First Name *

Last Name *

Email *

Phone *

2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

If public health has advised you that you do not need to self-isolate (for example, you are fully vaccinated or for another reason), select “No.”

Yes
No

3. In the last 14 days, have you traveled outside of Canada and been told to quarantine (per the federal quarantine requirements)? *

If public health has advised you that you do not need to self-isolate (for example, you are fully vaccinated or for another reason), select “No.”

Yes
No

4. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

Yes
No

5. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

If you are fully vaccinated (it has been 14 or more days since your the final dose of either a two-dose or a one-dose vaccine series), select “No.”

Yes
No

6. In the last 14 days, has anyone you live with been identified as a “close contact” of someone who currently has COVID-19 and been told to self-isolate by a doctor, healthcare provider, or public health unit? *

If you are fully vaccinated, select “No.”

Yes
No

7. In the last 14 days, has anyone you live with traveled outside of Canada and been told to quarantine (per the federal quarantine requirements)? *

If public health has advised you that you do not need to self-isolate (for example, you are fully vaccinated or for another reason), select “No.”

Yes
No

8. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *

If you have since tested negative on a lab-based PCR test, select "No."

Yes
No

9. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *

If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.” If you already went for a test and got a negative result, select “No.”

Yes
No