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Covid-19 Screening Questionnaire
Coronavirus (COVID-19) Screening Questionnaire
Please provide details prior to your next appointment.
Date
Personal Information:
Name
Address
Phone Number
Screening Questions:
Q1: Did the person have close contact with anyone with acute respiratory Illness or travel outside of Canada's capital (area) in the past 14 days?
Capital includes both side of the Ottawa river in Ontario & Quebec.
Q2: Does the person have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Q3: Does the person have any of the following symptoms:
You can choose more than one.
Fever
New onset of cough
Worsening chronic Cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue / malaise / muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
Q4: If the person is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
Patient Declaration:
Patient Declaration
I/We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are genuine.
Yes
Verification
Please enter any two digits
*
Example: 12
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Meet the Team
Dental Services
Prevention & Check Ups
Proactive Oral Hygiene Care
Dental Laser
Restoration
3D CEREC Technology
Endodontics Root Canal Treatment
White Filings
Extraction
Wisdom teeth
Inlays/Onlays
Same Day Dental Crown
Replacement
Dental implants
Dental bridges
Removable partial dentures
Complete dentures
Cosmetic Dentist
Smile Makeovers
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Invisalign® Dentist
TMD
Sedation
Sleep Apnea
Metcalfe Dental Experience
613-237-7177
Book An Appointment