COVID Questionnaire form

Our 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.