COVID-19 Screening Questionnaire
Patient Full Name
Patient Date of Birth (mm/dd/yyyy - ex: 02/06/1999)



The health and welfare of our patients and staff is our top priority.

Please complete the COVID-19 screening questionnaire below to confirm your appointment for optometric services at Academy Vision

Required Screening Questions:

1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.
Questions
Yes/No/?
Fever or Chills
Difficulty breathing or shortness of breath
Cough
Sore throat/trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles

2. Have you traveled outside of the country in the past 14 days?

3. Have you had close contact with a confirmed or probable case of COVID-19?

If you answered yes to any of the questions 1-3, please reschedule your appointment and contact your health care provider.

Signature of patient / legal guardian (type your name)



OFFICE HOURS    
Mon
9:00 - 5:00
Tue
9:00 - 5:00
Wed
9:00 - 5:00
Thu
9:00 - 5:00
Fri (Summer)
Closed
Sat
Closed
Sun
Closed
Extended & Weekend hours available upon request
Academy Vision
Dr. Marc Ullman,
Optometric Physician
NJ License # NJ 27OA00554700
OM# NJ 27OM00015000
90 Atlantic City Blvd.
Pine Beach, NJ 08741
(732) 736-1700
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Academy Vision 90 Atlantic City Blvd. Pine Beach, NJ 08741 Phone: (732) 736-1700

Academy Vision and Marc Ullman O.D. proudly serves Pine Beach, Toms River, Beachwood, Berkeley, Bayville, Lacey and surrounding areas.

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