COVID-19 Consent and Screening

Please note: all fields are required to be completed before the form will submit.
COVID-19 Eye care/Vision care Consent: I knowingly and willingly consent to have eye care/vision care services completed during the COVID-19 pandemic.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.
Your Name*
First Last
Please Confirm*
- I understand that despite social distancing and sanitization measures taken due to the frequency of patient visits, the characteristics of the virus, and the characteristics of eye care/vision care procedures, that I have an elevated risk of contracting the virus simply by being in a medical/eye care office.
Please Confirm*
- I have been made aware of the CDC guidelines that under the current pandemic I confirm that I am seeking eye care/vision care by consenting to this form
No COVID-19 Symptoms in the last 14 days: I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below, nor have I had any of these symptoms for the past 2 weeks, nor have I been in contact with any one with the symptoms below for the last 2 weeks:
Fever • Shortness of Breath • Dry Cough or any Respiratory Issue • Body Aches /Muscle pain • Sore Throat Cough • Chills/Repeated shaking • Headache • New loss of taste or smell
Please Confirm*
- I understand the importance of social distancing to prevent the spread of COVID-19 and confirm that I have not had any of these symptoms in the past 2 weeks.
No Travel in the last 14 days: I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus, and the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has traveled within the United States.
Please Confirm*
- I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.
Please Confirm*
- I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.
Please Confirm*
- I verify by cruise ship in the past 14 days
Signature*
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Alafaya Vision Center