Covid-19 Screening Questionnaire

Covid-19
Screening Questionnaire

Please provide details prior to your next appointment.

  • Date
  • YYYY dash MM dash DD
  • Personal Information
  • Screening Questions

    Did the person have close contact with anyone with acute respiratory Illness or travel outside of the National Capital Region* in the past 14 days?

    * includes both sides of the Ottawa river in Ontario & Quebec.

  • Does the person have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

  • Does the person have any of the following symptoms:

    You can choose more than one.

  • 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

    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.

  • Verification

    Please enter any two digits*

Testimonials

What Smile Denture & Implant Customers Are Saying

Excellent service. Got an appointment on short notice for urgent service. Rapid and efficient. Very helpful in explaining repair to be done on dentures. I definitely recommend this clinic.
Joanne Laflamme
Joanne Laflamme
My husband's denture broke and we were from out of province. Caner saw him within an hour and had his repair done same day. The staff (especially Caner) was friendly, professional and knowledgeable. The repair was excellent! I would recommend this clinic to anyone.
Noah Martinez
Noah Martinez
I was having terrible trouble with my bottom denture. Caner explained how he was going to fix it, he did within the week and now, holy moly, I can eat again. Fantastic!
Mick Pates
Mick Pates
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