COVID-19 Screening - In Focus Eye Care

Are you feeling sick?*

Examples of symptoms include new or worsening cough, headache, weakness, fever, chills, difficulty breathing, sore throat, unexplained fatigue

Have you experienced a recent loss of smell or taste?*

Have you been advised to self isolate for any reason?*

Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill?*

Name*

First Last

Date of your appointment*

Phone*

Comments (optional)