COVID-19 Screening Questionnaire
Patient Full Name
Patient Date of Birth (mm/dd/yyyy - ex: 02/06/1999)



The health and welfare of our patients and staff is our top priority.

Please complete the COVID-19 screening questionnaire below to confirm your appointment for optometric services at Today's Vision - Fuqua

Required Screening Questions:

1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.
Questions
Yes/No/?
Fever or Chills
Difficulty breathing or shortness of breath
Cough
Sore throat/trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles

2. Have you traveled outside of the country in the past 14 days?

3. Have you had close contact with a confirmed or probable case of COVID-19?

If you answered yes to any of the questions 1-3, please reschedule your appointment and contact your health care provider.

Signature of patient / legal guardian (type your name)



OFFICE HOURS    
Mon
9:00-5:00 
Tue
9:00-5:00
Wed
9:00-5:00
Thu
9:00-5:00
Fri
9:00-5:00
Sat
Closed
Sun
Closed
12804 Gulf Freeway
Suite 700A
Houston, TX 77034
Map it!

(832) 886-0080
Facebook   Instagram
Today's Vision - Fuqua 12804 Gulf Freeway Suite 700A Houston, TX 77034 Phone: (832) 886-0080 Fax: (832)-476-9549

Today's Vision Fuqua proudly serves Houston and the surrounding areas of Pasadena, Webster, Pearland, Friendswood, Deer Park, Galena Park, League City, Seabrook, La Porte and Sugar Land

© 2022 All content is the property of Today's Vision - Fuqua ™ & assoc. vendors. | DISCLAIMER | HIPAA
Website Powered and Developed by EyeVertise.com

Internal email | Internal forms