COVID-19 HEALTH QUESTIONNAIRE

Name: Sim Orthodontics
Address: 260 Hearst Way, Kanata, ON, K2L 3H1
Telephone: 613-591-1638

First Name*

Last Name*

Do you have any of the following NEW OR WORSENING symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever or chills in the last two weeks.

Yes

Cough, shortness of breath, difficulty breathing, sore throat, runny nose/stuffy nose or nasal congestion.

Yes

Recent decrease or loss of smell or taste.

Yes

Nausea, vomiting, diarrhea, abdominal pain.

Yes

Have you been in contact with any confirmed or probable COVID-19 positive patients or a person self-isolating because of a determined risk for COVID-19?

Yes

Have you returned from travel outside of Canada in the last 14 days?

Yes

Please note that-

If you have answered 'Yes' to any of the above questions, then please call or email our office to provide us with more details PRIOR to arriving for your appointment. We can be reached at 613¬591-1638 or drsim@primus.ca.

Information

Sim Orthodontics

260 Hearst Way

Kanata, ON

K2L 3H1

Phone: 613-591-1638

Email: info@simorthodontics.com

Hours

Monday: 7:30 AM – 4:30 PM

Tuesday: 7:30 AM – 4:30 PM
Wednesday: Varies
Thursday: 7:30 AM – 4:30 PM
Friday: Closed

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