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

Your first name *

Your last name *

Your age *

Are you immunocompromised? *YesNo

Do you have any of these symptoms? Choose any or all that are new, worsening and not related to o ther known causes or conditions.

Fever and/or chillsCough or barking coughShortness of breathDecrease or loss of taste or smellMuscle aches/joint painExtreme tirednessSore throatRunny or stuffy/congested noseHeadacheNausea, vomiting and/or diarrheaAbdominal painPink eye

Have you been told (by a doctor, health care provider, or public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home? *YesNo

In the last 10 days have you tested positive for Covid-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self testing kit? *YesNo

Rothwell Dental Center – Bilingual Gloucester Ottawa Dental Services

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Do you have any of these symptoms? Choose any or all that are new, worsening and not related to o ther known causes or conditions.