Ocean Park Optometry - COVID19 Wellness Form

COVID-19 Wellness and Check-In Form
Date *

Month Day Year
Date
Name *

First Name Last Name
Cell Phone Number *

Area Code Phone Number
Select any that apply to you *

I have a cough I have a fever I have difficulty breathing / short of breath been in contact with a someone with a positive COVID-19 test in the last 14 days I have been ordered to self isolate None of the above
Based on your response, you should postpone your visit.
- Please call 310-452-1039 and let's work out a plan.
- There are telehealth consultations available.
- Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing).
Based on your response, you are fine to come in. Please sign and submit this form. We will prepare for your entry.

Please remember that we can only allow the patient into the office. If under age 18, we allow one parent to accompany. Thank you.
Signature *

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Should be Empty:

Based on your response, you should postpone your visit.