COVID-19 Informed Consent

Informed Consent / Declaration for In-Office Visits during COVID-19 Pandemic
  • Please read carefully below:
  • Date Format: MM slash DD slash YYYY
  • I agree to the following:

    • I have not been in contact with someone who is known to have COVID-19
    • I have not had a fever, dry cough and fatigue in the last 14 days
    • I have not had aches, pains, nasal congestion, runny nose, sore throat, in the last 14 days
    • I have not travelled outside of Canada in the last 14 days
    • I am comfortable entering Innermedica at my own risk knowing I may come in contact with medical equipment which will be thoroughly sanitized and disinfected after each use
    • I will arrive at my appointment on time
    • I understand I have the right to change my appointment to telemed video or telemed phone consultation at any time
    • I understand that I must comply with Innermedica’s policies to protect my well-being and others in the clinic
    • Should I fail to comply to Innermedica’s policies, I understand that I may be denied access to the clinic



  • To ensure the safety of the community, please practice safety measures set forth by the public health authorities, before and after you enter the clinic. These include:

    • Make use of the washroom prior to your appointment and entering the clinic.
    • Please wait in your car until just one minute prior to your visit as there is no waiting room at the clinic.
    • Please wash hands and use hand sanitizers available in the office prior to your visit.
    • Masks and gloves are not required at this time and will not be provided. Please feel free to wear personal protective equipment that you feel most comfortable in to the office.