Eye Health Solutions patient intake form

  • Patient Advisory and Acknowledgment Receiving Eye and Vision Care During the COVID-19 Pandemic

  • Dear Patient: You have come to our office for evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following: While our office complies with Kentucky and CDC infection control guidelines to prevent the spread of COVID-19, we cannot make any guarantees, Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we are asking you a number of screening questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

  • Date Format: MM slash DD slash YYYY