COVID-19 Questionnaire | Jardon Eye Prosthetics

Which best describes you:*

Patient seeking to schedule an appointment
Legal guardian of patient
Friend or family member helping the patient schedule an appointment

Your Name (if not the Patient)

First Last

Patient Name*

First Last

Date of Birth*

The questions below apply to the patient who is requesting an appointment

Do you have a fever or have you felt hot or feverish recently or in the last 14-21 days?*

Yes
No

Are you having shortness of breath or other difficulties breathing?*

Yes
No

Do you have a cough?*

Yes
No

Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

Yes
No

Have you experienced recent loss of taste or smell?*

Yes
No

Are you in contact with any confirmed COVID-19 positive patients?*

Yes
No

(Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.)

Are you over 60 years of age?*

Yes
No

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

Yes
No

Have you traveled in the past 14 days to any regions affected by COVID-19?*

Yes
No

Additional Information

Please share any additional information we should know or concerns you would like us to address.

Contact phone number*

(for our team to call and either schedule an appointment with you or discuss the alternatives)

Consent*

I agree to sharing this health information with Jardon Eye Prosthetics

Thank you for your cooperation. Your health and safety are of the utmost importance to us. A member of our team will contact you regarding scheduling your appointment. We will contact you at the phone number you provided with approximately 24 hours or less. If you have an urgent issue you can always call us at 248-424-8560.

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