About Verbeek Kitchens and Bath, London ON

The Government of Ontario now require a screening survey to be completed by all essential and non-essential visitors upon their arrival. Further to this requirement, the London-Middlesex Region requires that masks must be worn when inside a workplace or when entering a business.

Verbeek Kitchens both expects and requires that this screening form be completed when ever meeting with one of our employees. Individuals that do not pass the screening questionnaire will not be permitted to enter our facilities or meet face to face until the screening questionnaire can be passed. In addition to this screening form Verbeek Kitchens requires all parties to be wearing a mask and always abide by the social distancing guidelines. This includes Verbeek Kitchens staff but also anyone meeting with our staff.

Individual Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region Postal Code

Phone Number*

Please enter a phone number that you can be reached at for the purpose of contact tracing. Your information will not be shared with outside parties.

Email*

Are you currently experiencing and of the following COVID-19 related symptoms?*

Click on any symptoms you are experiencing

Fever or Chills (temperature of 38 Degrees Celsius or higher)
Shortness of breath (out of breath, unable to breathe deeply)
Cough that's new or worsening (continuous, more than usual)
Sore throat or difficulty swallowing
Unusual headache, body or muscle aches
Loss of sense of taste or smell
Digestive issues (nausea / vomiting, diarrhea, stomach pain
Extreme tiredness that is unusual (fatigue, weakness or lack of energy)
None of the Above

Have you been in close contact with a confirmed or probable case of COVID-19?*

(Someone displaying symptoms waiting for results)

Yes
No

Where you asked to self-isolate by a healthcare professional, and have not yet completed the mandated 14-day isolation period?*

Yes
No

Have you or any member of your household recently returned from international travel in the past 14 days?*

Yes
No

Decleration*

I hereby confirm that the information provided herein is accurate, correct and complete and that the responses submitted within this form are genuine.

Agree

Email

This field is for validation purposes and should be left unchanged.