Logo


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 South Bay Optometry

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
8:30 - 6:00
Tue
9:30 - 7:00
Wed
8:30 - 6:00
Thu
8:30 - 6:00
Fri
8:30 - 5:00
Sat
8:30 - 2:00
Sun
Closed
South Bay Optometry
3537 Torrance Blvd
Suite 18
Torrance, CA 90503
Map it!

📱 (310) 543-3555
(310) 540-8363
Facebook   Instagram
South Bay Optometry, Inc. 3537 Torrance Blvd Suite 18 Torrance, CA 90503 Phone: (310) 543-3555 Fax: (310) 540-8363

© 2022 All content is the property of South Bay Optometry ™ & assoc. vendors. | DISCLAIMER | HIPAA
Website Powered and Developed by EyeVertise.com

Internal email | Internal forms