COVID-19 Pandemic Eye Exam and Treatment Consent

  • Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.

  • By signing this form below, I agree that I will not hold Anderson Eyecare or any of its doctors or team members personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge Anderson Eyecare and its doctors and team members for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.