Test form COVID-19 screening form11%Would you like to visit to our store?Due to Covid-19 we ask all customers to complete this form prior to your visit. Thanks for your understanding.StartHow would you like to be contacted?We may need to contact you to confirm your visit. EmailPhoneEmail addressPhoneBackNextHave you travelled outside of the country in the last 14 days?YesNoBackNextHas someone you are in close contact with tested positive for COVID-19 in the last 14 days?YesNoBackNextAre you in close contact with a person who is sick with new respiratory symptoms or who recently traveled outside of the country?YesNoBackNextDo you have a fever? (temperature ≥ 37.8°C)YesNoBackNextDo you have any of these symptoms?ChillsNew or worsening coughShortness of breath/difficulty breathingSore throatRunny or stuffy noseMuscle achesLoss of taste or smellHeadache that is unusualBackNextSorry you can not visit our store at this time We suggest you contact medical assistance.Please contact usWe may be able to help you via email or on the phone.BackNextChoose a prefered time slotWe will confirm your request within 48 hrs. We are open Monday-Friday, 9am to 5pm.MorningAfternoonDateBackSendThis field should be left blank
