General Disclosure Form

First Name *

Last Name *

Visit Date *

Location *

Phone number *

What time of day are you visiting? *

Resident and employee health and safety is taken very seriously at PARC Retirement Living.

Please complete the following screening questions not more than 24 hours prior to your visit.

Reason for Visit

Reason for Visit *

Vaccination Status

You are fully vaccinated if if you have two doses of any of the World Health Organization approved COVID-19 vaccines or one dose of the Janssen COVID-19 vaccine.

Are you fully vaccinated? *

NoYesNo

International Travel

Have you arrived in Canada after international travel in the last 7 days? *

NoYesNo

COVID-19 Testing Results

Have you had a COVID-19 test in the past 7 days (including self-test)? *

NoYesNo

COVID-19 Symptom Check

To keep our residents and staff safe, please carefully assess for symptoms daily.

Fever (over 37° Celsius or 100.4° Fahrenheit)? *

NoYesNo

Difficulty Breathing or Shortness of Breath *

NoYesNo

Loss of sense of smell or taste *

NoYesNo

Sore throat or worsening cough *

NoYesNo

Runny nose or nasal congestion *

NoYesNo

Nausea / Vomiting or Diarrhea *

NoYesNo

Headache *

NoYesNo

Increased or unusual fatigue *

NoYesNo

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Signature :

To All Visitors,

Upon arrival, please go directly to the Front Desk to have your temperature taken.

You will also be asked to show proof of your COVID-19 vaccination. If you have provided your proof of vaccination at an earlier visit, you may not be asked to show it again.

Thank you,

PARC Retirement Living

General Disclosure Form

Thanks for completing the form.

The receptionist has received your form and will review it.

Click the link below to learn how Colib can help you and your company with digital forms.

Thanks for completing the form.

The receptionist has received your form and will review it.

Click the link below to learn how Colib can help you and your company with digital forms.

Reason for Visit

Vaccination Status

International Travel

COVID-19 Testing Results

COVID-19 Symptom Check

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