COVID-19 PRE-SCREENING QUESTIONNAIRE
With the number of Coronavirus (COVID-19) cases rising daily and concerns of whether an outbreak could overwhelm our healthcare systems, we feel it is of paramount importance to be proactive in the way our clients are screened, in the event they are exposed to or are at risk of exposure to COVID-19.

In order to ensure the best interests of our staff when providing in-person services to you in our showroom or on your property and/or residence, we respectfully require everyoneโ€™s co-operation to assist us in determining whether or not we are able to provide in-person services to you.

Please note that these questions apply to all people who will be present during an in-person meeting.  The person completing this questionnaire is required to answer on behalf of everyone in their party. ๐—ช๐—ฒ ๐—ฎ๐˜€๐—ธ ๐˜๐—ต๐—ฎ๐˜ ๐—ฐ๐˜‚๐˜€๐˜๐—ผ๐—บ๐—ฒ๐—ฟ๐˜€ ๐—น๐—ถ๐—บ๐—ถ๐˜ ๐˜๐—ต๐—ฒ๐—ถ๐—ฟ ๐—ฝ๐—ฎ๐—ฟ๐˜๐˜† ๐˜๐—ผ ๐—ฎ ๐—บ๐—ฎ๐˜…๐—ถ๐—บ๐˜‚๐—บ ๐—ผ๐—ณ ๐Ÿฏ ๐—ฝ๐—ฒ๐—ผ๐—ฝ๐—น๐—ฒ ๐˜„๐—ต๐—ฒ๐—ป ๐˜ƒ๐—ถ๐˜€๐—ถ๐˜๐—ถ๐—ป๐—ด ๐—ผ๐˜‚๐—ฟ ๐˜€๐—ต๐—ผ๐˜„๐—ฟ๐—ผ๐—ผ๐—บ.

Please answer the following questions honestly and as accurately as possible:
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Name of Person Screened *
Customer Job Site Address *
Have you traveled outside of Canada within the last 14 days? *
Have you been in contact with anyone who has traveled outside of Canada within the last 14 days? *
Is the premise we are visiting inhabited by more than 5 people? (Note: this does not include customers visiting Mylenโ€™s Showroom located @ 33 Park Street, Chatham, ON) *
Have you come into close contact (within 6 feet) with someone who has a confirmed COVID-19 diagnosis within the last 14 days? *
Are you currently under self-isolation? *
Are you currently under quarantine? *
Do you have a new onset of any of the following symptoms: Fever/Chills, Runny nose/Sneezing, Sore throat/hoarse voice, Headache, Vomiting or diarrhea for more than 24 hours, Cough, Shortness of breath, Fatigue, Muscle aches? *
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