COVID-19 Intake Form Thank you for choosing the Sybesma Eye and Vision Center, where your health and safety is our primary focus. The AAO, AOA and other ophthalmology and optometry specific sources continue to share and update information regarding patient care, signs, symptoms and the ongoing efforts to understand and control the spread of COVID-19. To help protect our patients and staff against the spread of COVID-19, please answer the following questions:1. Have you or anyone in your household had a fever over 100 degrees F in the last three (3) days, respiratory symptoms (difficulty breathing, cough and/or shortness of breath), flu-like symptoms or have been in contact with anyone with a confirmed case of COVID-19?* Yes No 2. Other than healthcare professionals working in patient care, are you currently providing care for anyone who has been diagnosed with COVID-19, had a fever, cough, difficulty breathing or flu-like symptoms in the last 2 weeks?* Yes No 3. Have you traveled internationally or to a region affected by COVID-19 in the last 14 days?* Yes No 4. Are you or is anyone in your household under voluntary or involuntary quarantine in the last 14 days?* Yes No 5. Have you or anyone in your household traveled to an area with community spread of COVID-19 in the last 14 days?* Yes No If you have answered “YES” to any of the questions we are asking you to reschedule your appointment and contact your health care provider. We are practicing all preventative measures put forth by the Centers for Disease Control (CDC), including the use of alcohol and bleach -based disinfectants that are commonly used by Optometrists to disinfect our instruments and office furniture. The same disinfection practices already used to prevent office-based spread of viruses are happening before and after every patient encounter. We are anxious to serve you and appreciate your understanding of our new social distancing protocols at this time.Patient Signature*Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmailThis field is for validation purposes and should be left unchanged. Office Hours & Info Monday7:00am - 5:00pmTuesday8:00am - 7:00pmWednesday8:00am - 5:00pmThursday8:00am - 5:00pmFriday8:00am - 1:00pmSaturdayClosedSundayClosed 1408 43rd StreetMaquoketa, IA52060 563-652-2795 563-652-5210 [email protected]
