Form Builder

Appointment Booking Form – Risk and Release of Liability Declaration

June 10, 2021

Due to the global pandemic, the Town of Gravenhurst has enhanced protocals in place to protect visitors and our employees to limit the spread of COVID-19. The Town of Gravenhurst requires you to complete this form prior to attending Town Office. Preferred payment for serves is by credit card or cheque. Staff will contact you to confirm your appointment request.

COVID-19 Visitor Screening Questionnaire 

June, 2021

Please complete this questionnaire in order to schedule your appointment with Staff at Town Office.

  1. Are you currently experiencing one or more of the symptoms below that are new or worsening?                                                                                           

Symptoms should not be chronic or related to other known causes or conditions. 

For individuals who are 18 years of age and older: 

Do you have one or more of the following symptoms?  Please review and answer YES or NO Below;

Fever (hot to the touch or chills)

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough 

Continous, more than usual, makes a whistle noise when breathing

Shortness of breath

Out of breath, unable to breath deeply - Not related to asthma or other known causes or conditions you already have

Sore throat

Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have

Difficulty swallowing

Painful swallowing not related to other known causes or conditions you already have

Decrease or loss of smell or taste

Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Pink eye

Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)

Runny or stuffy/congested nose

Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Headache

Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have 

Muscle aches

Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Falling down often

For older people 

Exteme tiredness

Unusual fatigue, lack of energy



If you answered YES to any of these questions, you will not be permitted to schedule an appointment at this time.   

Please complete personal contact information below.

Completion of this declaration is mandatory. Failure to provide information will prevent you from visiting the facility. Please complete your details to confirm you have read and understood this declaration.

Declaration

  1. I hereby release and save harmless The Corporation of the Town of Gravenhurst and its employees and representatives from any and all claims and demands associated with my acquiring COVID-19, from visiting a Town of Gravenhurst site, due to any cause whatsoever, including negligence, breach of contract, mistakes or errors in judgment. This Release of Liability shall be binding upon my heirs, next of kin, executors, administrators, assigns and representatives.
Clear


Contact Us