To provide for the well-being and safety of all patients and staff members, we are asking each patient (parent or guardian for minors) to complete this sheet to assist us in screening for COVID-19 symptoms or risk factors.

Please initial after each statement indicating that you have read and attested the answer. The sign and date below. If you are not able to attest to all the statements below, we will need to reschedule your appointment today for a later date. We reserve the right to postpone scheduled appointments if a patient cannot attest to these statements.

• I attest that to the best of knowledge I do not have COVID-19
• I attest that I do not have a fever, cough, sore throat or other symptoms of a cold, influenza or COVID-19 and have not had any of these symptoms for the past 14 days
• I attest that I have not been in contact or in surroundings with someone who was positive for COVID-19 or who had any of these symptoms in the past 14 days

I have elected on my own volition to be seen in this office for eye or vision care services and understand that the doctor and staff have made every effort to provide a safe and healthy environment to see patients. I have been asked to wear a facial mask, to wash my hands or use hand sanitizer, avoid touching my face with my hands and to avoid close contact with other people while in the office to avoid potential for transmission of any virus.