• Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.

  • On March 16th 2020, The Centers for Disease Control and Prevention (CDC) issued the following public health reminder:

    Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now and for the coming several weeks. The following actions can preserve staff, personal protective equipment, and patient care supplies: ensure staff and patient safety: and expand available hospital capacity during the COVID – 19 pandemic:

    • Delay all elective ambulatory provider visits
    • Reschedule elective and non-urgent admissions
    • Delay inpatient and outpatient elective surgical and procedural cases
    • Postpone routine dental and eyecare visits

    I have read the above stated Public Health Reminder and have answered the health questions above honestly and to the best of my knowledge. I understand that Dr. Jonathan Gording, Optometry, APC, its doctors and staff are taking precautions to limit any potential exposure I may have to the COVID -19 virus. I also understand that there is no definitive way to eliminate potential exposure by one hundred percent.

    By signing this form below, I agree that I will not hold Dr. Jonathan Gording, Optometry, APC or any of its doctors or staff personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID – 19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge Dr. Jonathan Gording, Optometry, APC and its doctors and staff for injury, loss or damage arising out of my visit. I understand that COVID – 19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.

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