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New Covid-19 Screening Form

Title *
Date of Screening
Province *
LB Office *
Date of Visit *
Visitor Name *
Visitor Surname *
Telephone Number *
Cellphone Number *
Email Address *
Organization *
Date of Birth *
Have you recently travelled out of the province/country? *
If yes, please state province/country
Have you been in contact with someone recently diagnosed with COVID-19? *
Transport Used to Get to the Office? *
Visitor Personal Acknowledgement
Send Referral Letter?
Security Personnel