Brampton Office Registration
First Name
*
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Last Name
*
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Phone
*
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Email
*
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Are you a Realtor?
*
Are you a Realtor?
Yes
No
I am working with a Realtor
I am a Broker
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COVID-19 Self Assessment
Do you have any of the following new or worsening symptoms?
Fever/Chills?
*
Yes
No
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Cough?
*
Yes
No
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Difficulty breathing / Shortness of breath?
*
Yes
No
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Sore throat / Difficulty swallowing?
*
Yes
No
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Runny nose (unrelated to seasonal allergies)?
*
Yes
No
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Loss of taste or smell?
*
Yes
No
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Not feeling well, headache, unexplained tiredness and muscle aches?
*
Yes
No
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Nausea, vomiting, diarrhea, abdominal pain?
*
Yes
No
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In the last 14 days, have you had close physical contact with a person who was sick with a respiratory illness? Has returned from travel outside of Canada in the last 14 days? Was a confirmed or probable case of COVID-19?
*
Yes
No
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In the last 14 days, have you travelled outside of Canada?
*
Yes
No
This field is required.
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