Mezei Photography

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Have you had close contact with confirmed case of covid 19 in the last 14 days ? *

Yes

No

In the last 14 days have you or anyone in your household travelled outside of Canada ? *

Yes

No

Does anyone in your household have DIFFICULTY BREATHING / SHORTNESS OF BREATH ? *

Yes

No

Does anyone in your household have COUGH, SORE THROAT , RUNNY NOSE, HEADACHE, FEVER/CHILLS OR ACHY MUSCLES ? *

Yes

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Does anyone in your household have Decrease/loss of taste or smell , nausea or vomiting ? *

Yes

No

Are you or anyone in your household waiting for COVID 19 test results ? *

Yes

No