(613) 224-2332
booking@BaselineDentalCentre.com
1883 Baseline Rd.
Ottawa, Ontario K2C 0C7
Monday & Wednesday 8 A.M. - 5 P.M.
Tuesday & Thursday 8 A.M. - 8 P.M.
Friday 8 A.M. - 4 P.M.
Closed on Weekends
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COVID-19 Screening Questionnaire
New Patient Form
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Home
About
Services
Contact
Forms
COVID-19 Screening Questionnaire
New Patient Form
Update Medical History
Book an appointment
Baseline Dental Centre | Book an appointment
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Book an appointment
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Name
*
First
Last
Email
*
Phone
Dental surgery you are registered with
*
- Please select -
D. Hikal
D.Marie
When would you like to attend?
*
Date
Time
Appointments can be booked from Monday to Thursday.
Do you have any dental problems or concerns?
Tooth pain
Gum issues
Abcess
Enamel
Tooth color
Alignment
Broken tooth
Other
Please briefly describe your concern
Has anyone in your household experienced symptoms of Covid-19 in the last 14 days?
*
Yes
No
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