Thank you for joining our open house.

Name *

First Name

Last Name

Phone *

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Are you currently experiencing any COVID-19 symptoms (fever, cough, chest pain, difficulty breathing)? *

No

Yes

In the last 14 days, have you travelled outside of Canada? *

No

Yes

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

No

Yes