Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Booking

MM

DD

YYYY

1) Are you experiencing symptoms of a cough, fever, or having difficulty breathing *

Yes

No

2) Are you experiencing chills, fatigue, headache, sore throat, runny nose, stuffy or congested nose, lost sense of taste or smell, hoarse voice, difficulty swallowing or any digestive issues (nausea/vomiting, diarrhea, stomach pain) *

Yes

No

3) Have you been in close contact with a confirmed or probable case of COVID-19 *

Yes

No

4) Have you or someone close to you travelled outside of the province within the last 14 days? *

Yes

No

5) If you've travelled outside the province, have you followed necessary precautions upon re-entering Nova Scotia? (NS Safe Check-In) *

Yes

No

N/A