Patient Forms

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

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

Patient Forms

New Patient Form

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

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:

Patient Forms

New Patient Form

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

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:

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.