COVID Questionnaire form COVID Patient – Staff Questionnaire: MUST BE Completed and Signed prior to services being delivered. Please complete - print - and present at your appointment Potential Exposure means being in a house-hold contact or having a close contact within less than 6 feet of an individual with confirmed or suspected of COVID -19 (or other communicable contagion or disease). The timeframe for having contact with an individual includes the period of time one week before the individual has been potential exposed with consider incubation of 30 days. As such: we are mandating that all staff and patients read and sign the following:Location*SelectHopewellLambertvilleHave you had COVID?*YesNoWhen did you have COVID* Date Format: MM slash DD slash YYYY Have You been tested for COVID in the last 30 days?*YesNoWere you tested as*PositiveNegativeHave you had the COVID vaccine?YesNoHave you traveled outside the immediate or local area in the last 30 daysYesNoMethod of travel:AirTrainMass transitHave you been in any areas of risk such as a crowded risk environments like a gym, resturaunt, store in the last 2 weeks (14 days)YesNoHave you been in close contact or staying in the same househlod as someone who has demonstrated the above symptoms?YesNoDid you or have you been in contact with any individual(s) whom have been sick with COVID or tested positive for COVID within the last 30 days ?YesNoHave you been in close contact or staying in the same househlod as someone with a know or suspected case of COVID?YesNoDo you have or have any of the following symptoms within the last 30 days?YesNoFeverYesNoCoughYesNoDifficulty breathing or upper respiratory concernsYesNoPT’s entering temperature will be collected by staff Temp over 99.5F be to re-scheduled and asked to seek medical careTempOur offices are stringently following the guidelines of the CDC, NIH, AOA, AAphth. and other health agenices to safe guard our staff and patients, as seen on our website notice and posted notices in the office. The questions above are related to COVID or any other highly contagious disorders on a case by case basis. It is the discretion of the doctors of the offices of Hopewell and Lambertville Eye Associates to determine if it is appropriate to tend to the care of the individual based on the responses and the potential of risk to staff and other patients. Any false claims on this document will imply full liability for damages by the individual sigining this document representing themselves or any individual in their care. If care is deemed inappropriate at this time due to safety concerns, this is not deemed as a discriminatory act, but an act of protection and safety for all individuals. If a patient does not abide by the offices policy to maintain proper PPE or social distance, other than working directly, care will not not be delivered to the individual and not deemed discriminatory.Patient Name First Last Date of Birth Date Format: MM slash DD slash YYYY Name of person to accompany the patient First Last SignatureDate Date Format: MM slash DD slash YYYY Reviewed BY/ date