* Required

Your First and Last Name *

Your Email Address *

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? *
YesNo

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

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? *
YesNo

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. *
Yes

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

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

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. *
Yes