kimdoanmd.com - COVID19 QUESTIONNAIRE

COVID19 QUESTIONNAIRE

Advanced Eyecare / Kim Doan, M.D.
All patients/visitors are required to wear a face covering/mask.

Only 1 visitor per patient.

Contactless forehead temperature will be checked before upon arrival.

Equipment and rooms will be sanitized before and after each patient.

Contactless payment available via Apple/Google Pay.
Any fever 100 degrees or higher *

Yes No
Recent travel anywhere (domestic or international)? *

Yes No
Any exposure to someone who is sick? *

Yes No
Any of the following symptoms: *

Cough Shortness of breath Muscle aches GI upset Loss of taste or smell None
PLEASE SPEAK TO THE OFFICE STAFF ASAP!!!
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Date *

Month Day Year
Date
Should be Empty: