VISITORS WELLNESS CONFIRMATION FORM
Date:
Name:
Contact:
Address:
Myself and the members of my household, have been free of all
signs of illness, including cough, fever, trouble breathing or any
other respiratory issue for the past 72 hours.
I/we do not have a confirmed case of COVID-19 and I/we are not
under investigation for a potential case of COVID-19.
I/we have not, in the past 14 days, been in close contact with
anyone with a confirmed case of COVID-19 (or anyone under
investigation for a potential case of COVID-19)
In the past 14 days, I/we have not travelled outside of Canada or
came in contact with anyone who has recently travelled outside
Canada.
I/we have been following the guidelines set out by the Canadian
Government and have been self-isolating and practicing social
distancing
I/we verify the representations made above are accurate. I/we agree to maintain
a 6 feet distance from any service technician or trade partner who may have to
enter our property.
Name:
(Print) (Signature)
05/06/20
Faheem Suhail Patel
+1(647)5426865
20 shore breeze drive
Faheem Suhail Patel
