Covid Health Questionnaire

Toufexis Family Eye Care

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EVERY Patient New or Returning MUST fill out the COVID Health Questionnaire before coming in to the office.

Fill out the form below, your responses will be submitted directly to the office email. We will call you if we need to Reschedule your appointment.

Covid Health Questionnaire

* Indicates required field

Name *

First

Last

If you have been exposed to a communicable disease, you may spread the disease to the optometrist, optometrist staff or other patients in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you, your child, others accompanying you today or anyone else you have recently been in contact with have any of the following symptoms? *

Fever (defined as above 100.4F) Chills Cough Sore Throat Shortness of breath and/or trouble breathing Persistent muscle pain, pressure or tightness in the chest New loss of taste or smell None of the above

If Other please specify: *

Have you or others accompanying you to today's appointment traveled outside of our local area or outside of the US withing the past 14 days? *

Yes No

Have you, your child, others accompanying you today or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

Yes No

I understand that if the answer to any of these questions is yes, I may be asked to reschedule my appointment.

SUBMIT

Home
The Family
Insurance
Contact Lenses
Resources
Products
- Lenses

EVERY Patient New or Returning MUST fill out the COVID Health Questionnaire before coming in to the office.Fill out the form below, your responses will be submitted directly to the office email. We will call you if we need to Reschedule your appointment.