Name of guest:*

First Last

Your email address:*

Please check for any symptoms you are experiencing, or check "no symptoms" if none:*

Symptoms should not be chronic or related to other known causes or conditions.

Fever and/or chills, cough or barking cough (croup), shortness of breath
Decrease or loss of smell or taste, sore throat, difficulty swallowing
Runny or stuffy/congested nose, headache that is unusual or long lasting
Digestive issues like nausea, vomiting, diarrhea, stomach pain, muscle aches that are unusual or long lasting, or extreme tiredness that is unusual
No symptoms

Are you coming to our hotel to self-isolate or self-quarantine?*

Yes
No

Have you had close contact with anyone with a confirmed or probable case of COVID-19 in the past 14 days?*

Yes
No

Have you been tested for COVID-19 with results still pending, or diagnosed with a COVID-19 infection in the past 14 days?*

Yes
No

You acknowledge the contagious nature of the Coronavirus/COVID-19 and that Health Canada recommends practicing social distancing.

While we are taking all precautions and measures as laid out by the latest health guidelines, You acknowledge that we cannot guarantee that you will not become infected with COVID-19. You are staying at your own risk and waive any and all liabilities against the hotel and any and all parent and/or holding companies should you contract COVID-19 during Your stay.

By signing this form, I acknowledge that everyone coming in to my room has signed the COVID-19 screening. I also acknowledge that if I am to be found in violation of this policy, I will be asked to immediately find alternate accommodation at my own cost and will forfeit any money paid and owed to The Anndore House.

E-signature (enter your name here):*

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