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COVID-19 Update: What to Expect in Our Office  Click here to learn more.

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COVID-19 Questionnaire Form

COVID-19 Questionnaire

  • Please answer all of the following questions with a yes or a no:
  • If you answered yes to any of the above questions, you will be asked to please kindly reschedule your appointment for after 14 days. This is to further adhere to the safety compliance from the Ministry of Health and our College of Optometry, for all our patients, staff and doctors.

    Our office is taking strict precautions to limit any potential exposure to COVID-19 by sanitizing and disinfecting areas such as doorknobs, waiting room chairs, equipment, exam rooms, frames, restrooms etc, after each patient. All of our staff and doctors will be wearing personal protective equipment as well.

    We ask that you please kindly wear a mask or some mouth covering to your appointment. If you do not have one, you may purchase a mask at our office once you arrive. You will be asked to wash your hands or use sanitizer once you arrive as well.

    Please sign below that you have answered all the questions to the best of your knowledge and understand our office safety protocols.

  • Date Format: MM slash DD slash YYYY