COVID-19 Screening - 20/20 Law Group
Please complete this form prior to attending our offices for your scheduled appointment.
FILE NUMBER: Please enter your file number which should be in the format 200####-0##. If you don't have a file number, please leave blank.
On what date is your appointment with 20/20 Law Group? *
MM
/
DD
/
YYYY
At what time is your appointment with 20/20 Law Group? *
Time
:
With whom are you meeting at 20/20 Law Group? *
CORE SYMPTOMS: Please indicate whether or not you are experiencing any of the below symptoms right now. *
YES
NO
Runny Nose
Sore Throat
Shortness of Breath or Difficulty Breathing (new or worsening)
Cough (new cough or worsening chronic cough)
Fever
OTHER SYMPTOMS: Please indicate whether or not you are experiencing any of the below symptoms right now. *
NO
YES
Fatigue or Severe Exhaustion which has developed within the last 14 days.
Gastrointestinal Symptoms (nausea, vomiting, diarrhea, or unexplained loss of appetite)
Feeling Unwell which has developed within the last 14 days.
Painful Swallowing
Suffy Nose
Muscle or Joint Aches which has developed within the last 14 days.
Chills
Loss of Sense of Smell or Taste which has developed within the last 14 days.
Conjunctivitis (commonly known as "pink eye")
Headache
OTHER INDICATIONS: Please indicate whether or not any of the below applies to you.
YES
NO
I have travelled outside of Canada within the past 14 days.
I am a "close contact" to someone who has been diagnosed with COVID-19 in the last 28 days.
My workplace is considered "high risk" for COVID-19 (note that healthcare workers wearing appropriate PPE may answer "no" to this question).
I am waiting for the results of laboratory tests for the COVID-19 virus.
ACKNOWLEDGEMENT OF RISK: Please indicate whether or not you understand the below. *
NO
YES
Carriers of COVID-19 may not exhibit any symptoms and the virus can have an incubation period of up to 14 days.
There are high risk categoriy factors such as being over 65 years of age, heart disease, lung disease, kidney disease, or any auto-immune disorder.
Social distancing of 2 meters helps reduce the spread of COVID -19, but is not always possible to maintain during visits to the offices of 20/20 Law Group. I knowingly and willingly consent to attending the offices of 20/20 Law Group.
20/20 Law Group is taking all reasonable steps to protect its staff and clients from the COVID-19 virus by requiring certain safety measures such as mask wearing and hand sanitization, and by attending their offices I agree to abide by such measures.
Even where 20/20 Law Group takes all reasonable measures to protect people from the spread of the COVID-19 virus, if I attend the offices of 20/20 Law Group I may still come in contact with the COVID-19 virus.
I understand the risks of attending the offices of 20/20 Law Group during a pandemic, and have agreed to proceed with attending at the offices of 20/20 Law Group.
I have answered the questions in this form truthfully, honestly, and to the best of my ability.
I understand that 20/20 Law Group is relying on my answers in making the choice to see me in person during this pandemic.
As announced by the Provincial Government on May 13, 2021 face masks are mandatory unless you are able to provide proof of your exemption from this requirement. Please indicate that you understand that, when you arrive at our offices, you will not be allowed to enter our premises unless you are wearing a face mask or unless you have a doctor's note confirming your exemption. *
Required
Please note: depending on your answers, above, you may be contacted by our offices to either re-schedule your appointment or to change your appointment to a virtual one. We take the health and wellness of our staff, clients, and colleagues seriously, and are doing all that we can to mitigate the effects of the COVID-19 virus in our community. Please enter your initials in the field below before hitting submit. *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy