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COVID-19 Questionnaire

    I confirm the following statements to be true (check all that apply):

    Column A Symptoms (one symptom) Column B Symptoms (two symptoms)
    • Fever/Chills
    • Cough
    • Sore throat/hoarse voice
    • Difficulty breathing
    • Loss of taste or smell
    • Vomiting or diarrhea for more than 24 hours
    • Runny nose
    • Muscle aches
    • Fatigue
    • Pink eye (conjunctivitis)
    • Headache
    • Skin rash of unknown cause
    • Poor feeding, if an infant
    • Nausea or loss of appetite

    I acknowledge and agree that:

    g. In the event that during the next 14 days I should experience any of the symptoms as set out in (d), or learn of any circumstances that would change my response to any of the above questions I will immediately inform the Listing Brokerage.

    h. I am aware of the inherent health risks and concerns related to my attendance at the property, or my allowing others to attend at the property, and with any contact I may have with those involved. I am allowing or participating in the viewing of the property at my own free will and accord. I will not hold the occupants of the property, other who attend at the property, the Listing Brokerage, or any of their representatives for any claims, costs, damages, expenses or liability related to any adverse health related consequences arising as a result of allowing or having access to the property for the purpose of viewing it.

    i. The information contained in this declaration may be retained by the Listing Brokerage for a period of up to eight weeks. In the event the Listing Brokerage considers it necessary for public health purposes to release this declaration or any information contained herein to any health authorities or anyone else, they may do so.

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