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COVID-19 Screening Form
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757-426-2020
COVID-19 Screening
Appointment Location
*
Volvo Parkway Office (1116 Volvo Parkway, Ste 102 Chesapeake, VA 23320)
Red Mill Office (2033 Fisher Arch, Ste 150 Virginia Beach, VA 23456)
Salem Crossing Office (2077 Lynnhaven Pkwy, Ste 101 Virginia Beach, VA 23456)
Harbour View Office (2051 Sun Harbour Ave, Ste 110 Suffolk, VA 23435)
Patient Name
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Last
Person Completing Form
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Last
Relationship to Patient
Email
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Are you experiencing any of the following
Fever
Abnormal Body Aches
Difficulty Breathing
Recent Onset of Severe Coughing
Have you been around anyone with the above symptons in the last 14 days?
*
yes
no
Have you tested positive for COVID-19 in the last 14 days?
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yes
no
Have you been around anyone who has tested positive for COVID-19 in the last 14 days?
*
yes
no
Have you had known contact with anyone that has tested positive for COVID-19 or has experienced symptons listed above?
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yes
no
Are you a cancer patient undergoing treatment?
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yes
no
If the answer is yes to any of the above questions, we cannot see you unless for ocular emergencies with specific clearance by the patient's primary care physician.
Are you above the age of 65?
*
yes
no
If you are 65 or older, the CDC considers you a person at higher risk. We can still see you if you have pressing issues to be addressed by our doctors or need new glasses or contact lenses. If there is no pressing need, it may be best to wait until local COVID-19 risk factors decrease.
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