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Located in Ramsey Medical Center in Ramsey, NJ
Call 201-884-1717
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Walter Shurminsky O.D.

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Home » Contact Us » COVID-19 Pre-visit Patient Screening Form

COVID-19 Pre-visit Patient Screening Form

  • All patients will have a pre-visit screening phone call or be asked to fill out online and email to us pre-visit for exposure risk to COVID-19 and symptoms of respiratory illness.

  • Pre-visit

  • Day of Visit

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Have you or your visitor with you today had any of the following symptoms in the past 3 days?

  • *If the answer is NO to all of the above, the patient may come in on their scheduled appointment date.

    *If the answer is YES to any of the above, the patient will be advised to call their primary care doctor and reschedule their appointment.

  • Pre-visit

  • Day of visit

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Covid-19 Testing Questions:
  • Date Format: MM slash DD slash YYYY
  • If the test was positive, patient needs to reschedule at least 14 days after symptoms are gone or are cleared by their primary care doctor.

COVID-19 Update: Our office will be reopening for routine eye care on Monday, June 1, 2020. Appointments will be limited at first so call or schedule using our online scheduler.

For a list of updated COVID-19 protocols and procedures that we are implementing in our office for your safety as well as the safety of our staff, click here.