Name *

First Name

Last Name

In the last 14 days, have you travelled outside of Canada? If exempt from federal quarantine requirements (for example, an essential worker, select “no”). *

YES

NO

Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (staying at home)?This can be because of an outbreak or contact tracing. *

YES

NO

Are you currently experiencing any of the symptoms? Fever and/or chills, coughing, shortness of breath, decrease or loss of smell or taste, sore throat, difficulty swallowing, runny or stuffy/congested nose, pink eye, headache, digestive issues like nausea/vomiting, mussel aches, extreme tiredness. *

YES

NO

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

YES

NO

Are you and everyone in your household (over 12+) vaccinated against COVID-19?

YES

NO

I agree to the above terms and conditions for an In Home Art Consultation.

YES

NO