Ottawa Denturist I Ottawa Denture Clinics I Denture Implants

Coronavirus (COVID-19) Screening Questionnaire

    Please provide details prior to your next appointment.

    Personal Information:

    Screening Questions:

    Capital includes both side of the Ottawa river in Ontario & Quebec.

    You can choose more than one.

    FeverNew onset of coughWorsening chronic CoughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsHeadachesUnexplained fatigue / malaise / muscle aches (myalgias)Nausea/vomiting, diarrhea, abdominal painPink eye (conjunctivitis)Runny nose/nasal congestion without other known cause

    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.



    Example: 12