The Covid-19 pandemic has changed the business world dramatically. We are delighted to be servicing you again at your home. However, in order to protect you and our wonderful staff, there are certain safety steps that need to be taken. Please carefully read every question and fill out the survey truthfully. Once we have received your answers, we will review everything and contact you afterwards. Please note that Euro-Parts & Eurohome staff members reserve the right to immediately leave the premises if social distancing rules and safety measures are not being followed during the visit. Type of Visit*Service CallDelivery onlyDelivery and installation Name*FirstLast Address* Street Address City Postal / Zip Code Phone number* Email Have you or anyone in your household been diagnosed with COVID-19, or do you think you've had/have COVID-19?*YesNo Test method used: If YES, when were you or the household member confirmed positive? If YES, if you or the household member has had COVID-19, have you been confirmed negative afterwards?YesNo If you or the household member have had COVID-19, when were you or the household member confirmed negative?today24 hours ago10 days after testing Do you or a household member currently have or recently have experienced in the past 4 weeks: Fever*yesno Do you or a household member currently have or recently have experienced in the past 4 weeks: Altered or loss of taste/smell*YesNo Do you or a household member currently have or recently have experienced in the past 4 weeks: Dry Cough*YesNo Do you or a household member currently have or recently have experienced in the past 4 weeks: Trouble breathing*YesNo Do you or a household member currently have or recently have experienced in the past 4 weeks: Shortness of breath, difficulty breathing, chest tightness*YesNo Do you or a household member currently have or recently have experienced in the past 4 weeks: Chills/ repeated shaking with chills*YesNo Do you or a household member currently have or recently have experienced in the past 4 weeks: Headache or sore throat*YesNo Do you or a household member currently have or recently have experienced in the past 4 weeks: Any other flu-like symptoms*YesNo Are you or have you been in contact with anyone who has been sick and/or confirmed to be COVID-19 positive?*YesNo In the past 4 weeks have you or someone you have been traveled to any regions affected by COVID-19?*YesNo During the visit from the Euro-Parts/Eurohome staff member, I and all my household members will stay away from the staff member at least 5 meters at all times (preferably I/we will be in a different room)*Yes During the entire visit from the Euro-Parts / Eurohome staff member, everyone present will be wearing a mask*Yes I/we hereby acknowledge that we have filled out this questionnaire truthfully and that we will adhere to the social distancing rules during the entire time of the visit*Yes Space for further comments you'd like to share with Euro-Parts / EurohomeSend a copy of this message to yourselfSubmitReset
