Visitor Health Screening Questionnaire

If this form isn’t available please contact us instead

The health and safety of our employees, customers, families and visitors remains the top priority of the Heritage Group. As the Coronavirus situation continues to evolve globally, we’re asking you to complete this screening to help prevent the spread of or exposure to COVID-19.

Please note that visitors will be required to wear a mask upon entering the showroom.

Heritage Office Visitor Health Screening Questionnaire

Visitor Name * Required
Visitor Phone Number * Required
Company Name
Heritage Office Host * Required
Facility Name * Required
Planned Date of Heritage Visit - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Have you travelled internationally within 14 days of your visit to Heritage? * Required
- Yes
- No
Have you 1) been diagnosed, 2) been in contact with someone who has been diagnosed, or 3) been in contact with someone who may have been exposed (e.g. travelled internationally) with COVID-19 within 14 days of your visit to Heritage? * Required
- Yes
- No
Have you experienced any cold or flu-like symptoms (including fever, cough, sore throat, respiratory illness, difficulty breathing) within 14 days of your visit to Heritage? * Required
- Yes
- No