COVID-19 | Rothwell Dental: Full Dental Services in Gloucester & Ottawa

Your first name *

Your last name *

Your age *

In the last 14 days have you been directed by a border agent to comply with federal quarantine requirements due to international travel? *YesNo

In the last 5 days (if fully vaccinated) or 10 days (if unvaccinated or immunocompromised), have you experienced any of the following symptoms? *YesNo

Fever and/or chills
Extreme fatigue
Cough
Sore throat
Shortness of breath
Runny or stuffy/congested nose
Decrease or loss of taste or smell
Headache
Muscle aches/joint pain
Nausea, vomiting and/or diarrhea

Do any of the following apply? *YesNo

You live with someone who is currently isolating because of a positive COVID 19 test
You live with someone who is currently isolating because of COVID 19 symptoms
You live with someone who is isolating while waiting for COVID 19 test results

In the last 5 days (if fully vaccinated) or 10 days (if unvaccinated or immunocompromised), have you tested positive on a rapid antigen test, molecular test, or home-based self testing kit? *YesNo

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *YesNo

Rothwell Dental Center – Bilingual Gloucester Ottawa Dental Services Dr. Andre Theoret

Cliquez ici pour le formulaire de dépistage COVID-19 en français