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Walter Shurminsky O.D.

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COVID-19 Pre-visit Patient Screening Form

  • All patients and their vistor must complete a pre-visit online form for exposure risk to COVID-19 and symptoms of respiratory illness prior to their appointment.
  • 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.

  • 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.