COVID Declaration | Ben Thanh London

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Phone

You don't have one of these symptoms: 1) Fever or Chlls (body temp higher than 98.6°F/ 37.5°C) 2. Cough or barking cough (croup) 3. Decrease or loss of smell or taste 4. For adults 18 years or older: Fatigue, Lethargy, Malaise and/or Myalgias | For children under 18 years: Nausea, Vomiting and/or Diarrhea (Not related other known causes or conditions you already have)

In the last 14 days, you haven't travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

A doctor, health care provider, or public health unit has not told you that you should currently be isolating (staying at home) due to an outbreak or contact tracing.

In the last 10 days, you haven't been identified as a “close contact” of someone who currently has COVID-19? Also, public health has not advised you to self-isolate (e.g., you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared).

I declare that the info I’ve provided is accurate & complete

Date

Thanks for submitting!