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We will be closed Friday April 3 and reopen April 4 regular business hours. Any medical emergency call 911 or go to the nearest medical facility.

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FAMILY & SPECIALTY MEDICINE & WALK-IN
416-222-6160
2 Champagne Drive: East Entrance
Champagne Centre
Toronto, ON M3J 0K2

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- Walk-in Clinic
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- Physicians Accepting New Patients
Specialty Medicine
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Contact
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Home
Walk In Clinic
- Walk-in Clinic
Family Medicine
- Physicians Accepting New Patients
Specialty Medicine
Services
About Us
Resources
- For Patients
- For Physicians
Contact
Search for:

COVID-19 Pre-Screening Questionnaire

Home/COVID-19 Pre-Screening Questionnaire

COVID-19 PRE-SCREENING QUESTIONNAIRE
Please complete our COVID-19 screening 1 – 2 days before your scheduled in-person appointment
To help our health professionals with your assessment and as a precaution to limit the risk of transmitting the COVID-19 virus, it is important we take measures to protect our patients, staff and physicians.
Name*
First Last
Date Of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Phone Number*
Department you are scheduled for:*
Kindly answer the below questions before seeing the physician or having your testing done:
1) Are you experiencing symptoms of a cough, fever, or having difficulty breathing*
- Yes
- No
2) Are you experiencing chills, fatigue, headache, sore throat, runny nose, stuffy or congested nose, lost sense of taste or smell, hoarse voice, difficulty swallowing or any digestive issues (nausea/vomiting, diarrhea, stomach pain)*
- Yes
- No
3) Have you been in close contact with a confirmed or probable case of COVID-19*
- Yes
- No
4) Have you been tested for COVID-19*
- Yes
- No
What was the result?*
- Positive
- Negative
- Awaiting Results
a) Date of your positive test*
MM slash DD slash YYYY
b) Did you isolate the greater of;
i) 14 days after testing positive OR*
- Yes
- No
ii) 14 days from when symptoms started OR*
- Yes
- No
iii) Until symptoms were gone*
- Yes
- No
5) Have you or someone close to you travelled outside of Canada within the last 14 days*
- Yes
- No
If you answered yes to any of the questions, please explain below:
If you answer yes to any of the above questions, do not come into the clinic. Call our office to re-schedule your in-person appointment and call Telehealth Ontario at 1-866-797-0000
If you have additional questions, please contact Health Connection, Monday to Friday from 8:30 am to 4:30 pm at 1-800-361-5653. After hours please call Telehealth Ontario at 1-866-797-0000.

October 8, 2020
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Date of form submission: 04/04/2026

Polyclinic Family and Specialty Medicine located in North York

Family & Specialty Medicine
Walk-in Clinic
2 Champagne Drive
Champagne Centre
Toronto M3J 0K2

Book an Appointment

9am-8pm Monday-Friday
Saturday 9am-1pm or by appointment
OR visit our walk-in clinic directly

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