Home Services Residential Rez-Internet Rez-Phone Rez-Television Rez-Wifi Rez-Bundles Business Biz-Internet Biz-Phone Biz-Wifi Biz-Television Biz-Custom Sign Up Now Billing Support Installation Trouble Shooting Trouble Report Speedtest Contact Us About COVID-19 Screening Form All Items must be filled out before this form can be submitted.Customer Contact InformationFirst NameLast NamePhone NumberEmail addressService Call DateTravel InformationDid you or any member of your household travel outside of Ontario in the past 14 days?YesNoDid you or any member of your household have a confirmed case of COVID-19, or contact with anyone that has?YesNoSymptom Information - Are you or any member of your household experiencing any of the following symptoms?FeverYesNoShortness of breathYesNoDifficulty swallowingYesNoHeadachesYesNoPink eyeYesNoNew onset of coughYesNoDifficulty breathingYesNoDecrease of loss of sense of taste or smellYesNoUnexplained fatigue/malaise/muscle achesYesNoWorsening chronic coughYesNoSore throatYesNoChillsYesNoNausea/vomiting, diarrhea, abdominal painYesNoRunny nose or nasal congestion without known causeYesNoAge InformationAre you or any member for your household 70 years old or older?YesNoIs any member of your household older than 70 experiencing any of the following symptoms?DeliriumYesNoAcute functional declineYesNoUnexplained or increased number of fallsYesNoWorsening of chronic conditionsYesNoSubmit ReportBy submitting this form you are confirming that to the best of your knowledge all of the information provided is correct. Thank you for helping us protect one another from COVID-19.Please enable JavaScript to submit this form.Submit
