Covid-19 Screening - Metcalfe Street Dental - Downtown Ottawa Dental Implant and Family Dental Clinic

Day Of Appointment

Have you had close contact with anyone with acute respiratory illness or traveled outside of Ontario in the past 14 Days?

Yes
No

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

Yes
No

Do you have any of the following symptoms: Fever, New Onset Cough, Worsening Chronic Cough, Shortness Of Breath, Sore Throat, Difficulty Swallowing, Decrease Or Loss Of Sense Of Taste Or Smell, Chills, Headaches, Unexplained Fatigue - Malaise - Muscle Aches, Nausea, Vomiting, Diarrhea, Abdominal Pain, Pink Eye, Running Nose, Nasal Congestion Without Other Known Cause?

Yes
No

Are you 70 years of age and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Yes
No

Covid-19 Screening Form

Screening Questions

Pre-Screen

Day Of Appointment

Patient Acknowledgement

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Clinic Hours

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