COVID Pre-Screening

By submitting this form, you agree to follow current health guidelines set forth by the Ministry of Health and Public Health Ontario. You also understand that you are required to wear face coverings (over the nose and mouth), medical or non-medical grade face masks at all times while you are in the Sport Medicine Clinic. You understand that the Sport Medicine Clinic cannot guarantee that you will not contract the virus, even when implementing screening protocols. You further understand that safety is a shared duty, COVID-19 is a shared risk, and all community members, including staff and patients of the Sport Medicine Clinic, must follow required protocols set in place by the Sport Medicine Clinic, to promote health and safety.

  • Appointment Information

  • - -
  • :
  • Patient Name

  • By checking the boxes, you confirm that you agree with the following statements:

  • Infection Control Protocols:

  • 1. Screening Questionnaire - please submit the required screen 24 hours prior to your 1st appointment AND prior to each follow-up visit.

    Depending on your answers, we may have to reschedule your appointment. Your therapist will contact you to discuss your answers if required.

    *Please do not come into the Clinic if you have any symptoms, your therapist will be in touch directly and determine the timeline for when your appointment is to be rescheduled.*

    *We continue to strive for our Clinic reception to be contact-less. We really appreciate our patients completing their screens electronically in advance and for providing a payment option on file to be able to bill direct and email out receipts.*

    2. All therapists and patients are required to wear a mask while in the Clinic. Please bring a clean medical or cloth mask with you to your appointment and apply your mask prior to entering the Clinic.

    *Please note: all patients are now required to wear a mask indoors as per the City of Toronto bylaw*

    3. When you arrive at the Sport Medicine Clinic, you can wait in our waiting room where we have chairs socially distanced.

    4. Please wash or sanitize your hands upon entering the Clinic. We have a sink available for handwashing inside the Clinic. There will be alcohol-based hand sanitizer (70% alcohol) available in the lobby outside the Clinic, at the reception desk and waiting area, and in the treatment rooms.

    5. Between every appointment, therapists will thoroughly clean and disinfect the treatment room, including beds, common touch surfaces, and equipment using disinfectants approved by Health Canada to kill COVID-19.

    6. Please come to the Clinic prepared with your own shorts and a t-shirt/tank top to change into for your assessment or treatment.

  • I agree not to visit the Sport Medicine Clinic for any of the services provided if I have the symptoms of COVID-19, unless explicitly cleared by the provider with whom I am receiving treatment at time of appointment. I acknowledge that the information I have given in this consent form is accurate and complete. By typing my name below, I confirm that I understand and agree to all terms and statements in this form.