Health Declaration

Under Ontario Orange Restrict - Intermediate Measures, screening is required of patrons in accordance with instructions issued by the Office of the Chief Medical Officer of Health. This information shall only be given to Health officials upon request.

All patrons must fill out this form before being served at Glebe Central Pub. Thank you for your understanding.

First Name

Last Name

Email or Phone Number

My body temperature is lower than 98.6°F/ 37.5°C

Are you experiencing any symptoms of the following; fever and/or chills, cough or barking cough, shortness of breath, sore throat, difficult swallowing, runny or stuffy/congested nose, decrease or loss of taste or smell, pink eye, headache, digestive issues like nausea/vomiting, diarrhea, stomach pain, muscle aches, extrem tiredness, falling down often?

Yes

Please read the following? If you check any of the following boxes, kindly vacate and return to your home.

Travelled outside of Canada with the last 14 days?

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

Date

Time

I confirm that the information given in this form is true

A PLACE TO SHARE WITH FRIENDS AND NEIGHBOURS

WINE, WHISKEY, DRAUGHT, COCKTAILS, SPIRITS & ALES

Health Declaration