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 a fever or have felt hot or feverish anytime in the last two weeks?

Yes

Do you have any of these symptoms? Dry cough. shortness of breath, difficulty breathing. sore throat, runny nose

Yes

Have you experienced a recent loss of smell or taste?

Yes

Have you been in contact with any confirmed COVID-19 positive patient(s) 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

Have you returned from travel within Canada from a location known to be affected by COVID-19?

Yes

Are you over the age of 60?

Yes

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

Yes

Please note that-

If you have answered ‘No’ to all of the above questions, please return to the text or email and confirm your appointment.

If you have answered ‘Yes’ to any of the above questions, then please call our office at (613) 591 -1638

Information

Sim Orthodontics

260 Hearst Way

Kanata, ON

K2L 3H1

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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