COVID-19 Consent Form

新型コロナパンデミック中にご来社の方へ

PLEASE COMPLETE THIS FORM ONE DAY BEFORE YOUR APPOINTMENT

As recommended by the BC CDC, we are asking clients to review the following information and complete the questionnaire prior to their scheduled appointment. If you have any questions regarding this form, please call our office at 604-684-5772. Thank you for your understanding and cooperation!

If you have concerns or questions about your health, please contact HealthLinkBC (8-1-1) or speak with your health care provider.

* Required

Do you have any new cold or flu-like symptoms in the past month such as fever, chills, muscle aches, cough, sore throat, runny nose or loss of sense of smell? *

Have you been in contact with anyone who has tested positive for COVID-19 or suspected of having COVID-19 in the past month? *

Have you been in a setting in the last 14 days that has been identified by public health as a risk for acquiring COVID-19, such as on a flight, in a workplace with a cluster of cases, or at an event? *

COVID-19 CLIENT CONSENT FORM

I understand that due to the visits of other clients, the characteristics of COVID-19, and the characteristics of office procedures, that the client has an elevated risk of contracting and spreading COVID-19 by being in the Visa JP Canada office. *

I confirm that the client does NOT have any symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose, headache, etc. *

I confirm that this is not currently a period where the client is required to self-isolate for 14 days. *

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have counseling or consultation completed during the COVID-19 pandemic. *

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