COVID-19 Screening Questionnaire

In an Effort to Stay Safe and to Stay Open, We Need Your Help.

Please answer the following questions regarding your potential exposure to COVID-19

MM slash DD slash YYYY
Do you have a fever or any other COVID symptoms?(Required)
Have you had a positive COVID test in the past 30 days?(Required)
Are you awaiting COVID test results?(Required)
Are you currently in a recommended quarantine (school or work)?(Required)
Do any of the above apply to someone in your household?(Required)
If you answer yes to one or more of the above, please bring your paperwork back to the front desk and we will review the details of your potential exposure.
Thank You for Your Continued Understanding and Cooperation, Dr. John, Dr. Terri, & the Entire Anderson Eyecare Team
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