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 Adelaide Health Clinic. You understand that the Adelaide Health 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 Adelaide Health Clinic, must follow required protocols set in place by the Adelaide Health Clinic, to promote health and safety.

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  • Appointment Information

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  • Client Name

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



  • Do you have any of these symptoms?

    If you do not have any of these symptoms, please select No Symptoms.




  • Infection Control Protocols:

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

    If you answer NO to all the screening questions, you will be able to keep your appointment. If you answer YES to any of the questions, 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 Adelaide Health Clinic in First Canadian Place, you can choose to wait in our waiting room where we have chairs set up or you may wait outside the Clinic until you are called in. If you choose to wait outside, please knock on the door to inform our receptionist that you have arrived. Your therapist will come and get you when they are ready for you.

    4. Please wash or sanitize your hands upon entering the Clinic. We have a sink available for handwashing inside the Clinic that is specifically designated for patients. There will be alcohol-based hand sanitizer (70% alcohol) available at the front doors, at reception, and in the treatment rooms.

    5. We have built in cleaning breaks between every appointment to allow us time to 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, if required. You may either change in our patient designated washroom or in your therapist's treatment room prior to beginning your appointment.

  • I agree not to visit the Adelaide Health 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.