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*

Have you had COVID?*

Yes
No

When did you have COVID*

Have You been tested for COVID in the last 30 days?*

Yes
No

Were you tested as*

Positive
Negative

Have you had the COVID vaccine?

Yes
No

Have you traveled outside the immediate or local area in the last 30 days

Yes
No

Method of travel:

Air
Train
Mass transit

Have 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)

Yes
No

Have you been in close contact or staying in the same househlod as someone who has demonstrated the above symptoms?

Yes
No

Did 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 ?

Yes
No

Have you been in close contact or staying in the same househlod as someone with a know or suspected case of COVID?

Yes
No

Do you have or have any of the following symptoms within the last 30 days?

Yes
No

Fever

Yes
No

Cough

Yes
No

Difficulty breathing or upper respiratory concerns

Yes
No

PT’s entering temperature will be collected by staff Temp over 99.5F be to re-scheduled and asked to seek medical care

Temp

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.

Patient Name

First Last

Date of Birth

Name of person to accompany the patient

First Last

Signature

Date

Reviewed BY/ date