Skip to main content
Menu

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.

  • 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

  • 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.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.