Name *Phone *Email AddressNumber of people in your party*PEOPLE SEATED AT A TABLE TOGETHER MUST BE FROM THE SAME HOUSEHOLD Date of visit *Time of visit *Hours010203040506070809101112Minutes000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMHave you been diagnosed with Covid-19 or have you been tested and waiting to hear the results? *YesNoHave you been told by Public Health that you may have been exposed? *YesNoHave you been experiencing any symptoms? If yes, please list them below.Is the information provided above true & correct?Yes, I hereby certify that the information provided is true & correct.GDPR *Yes, I agree with the privacy policy and terms and conditions.Send Message
