pre-appointment questionaire

IMPORTANT: Completion of this form is required for every appointment. Even for subsequent visits such as office visit or contact lens follow-ups. You will forfeit your appointment if this form is not complete two days prior to the date of your appointment.

Patient's Name

First Name

Last Name

Email

Phone

(###)

###

####

Please select the reason for your visit

Need to purchase glasses and/or contact lens

Office visit for painful, red, watery or irritation of the eye(s) or other visual disturbances.

Routine eye exam with stable vision or do not need vision correction.

Doctor directed follow-ups for office visits or contact lens

IMPORTANT! Please check all that apply:

Please be truthful in your response. We need your cooperation to ensure safety for our staff and patients.

In the last 14 days, patient or any household member(s) have experienced: fever, cough, shortness of breath, chills, sore throat, loss of taste or smell, or muscle pain.

Patient or household member(s) have been diagnosed with COVID-19.

Patient have been in contact with someone who have tested positive for COVID-19.

Patient have traveled in the last 2 weeks.

None of the above statements are applicable

Please note:

All visitors must wear a face mask covering their mouth and nose during their entire visit.
At your visit, we will check your temperature and if it is higher than 100, we will reschedule you.
Please come alone for your appointment. A minor may be accompanied by one guardian.
Should your reponses regarding COVID-19 be different at your appointment date, we may need to reschedule you.

Questionnaire

pre-appointment questionaire

Please note:

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