COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form
Date of Birth:
Please read the following statements and INITIAL next to each statement to indicate your
agreement. If you cannot positively affirm to all these questions, you will be asked to
postpone or reschedule your visit to a later date.
I DO NOT currently, nor have I had in the last two weeks, a fever, cough, sore throat, loss of smell/taste or other cold symptoms.
To the best of my knowledge, I DO NOT have, nor have I been in direct contact with someone who has a confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last 30 (thirty) days.
Neither I, nor anyone living in my immediate household, have traveled outside of the State of Texas in the last 30 days.
I have not traveled outside the US in the past 14 days to countries that have been affected by COVID-19.
I have not traveled domestically within the US by commercial airlines, bus, train, or personal vehicle within the last 14 days.
The Centers for Disease Control and Prevention (CDC) has stated routine eye care may resume,
as clinically appropriate, on an outpatient basis. However, they have issued the following Public
Health Reminder to healthcare providers.
• Healthcare providers and staff must wear surgical facemasks at all times.
• Patients should wear a surgical facemask or a cloth face covering made at home or bought.
• Healthcare providers and staff are routinely checked for COVID-19 symptoms.
• Patients should be screened for possible COVID-19 symptoms prior to entering the facility.
• Ensure thorough cleaning and disinfection of facility pre and post patient care.
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. Mija Jackson Lee, 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
By signing this form below, I agree that I will not hold Dr. Mija Jackson Lee, PLLC or any of its doctors or
staff personally responsible should I, or someone I come in contact with, become positively or
presumptively positively diagnosed with the COVID-19 virus. There are certain inherent risks
associated with an eye exam during an epidemic and I assume full responsibility for any personal
illness that may result from this exam. I further release and discharge Dr. Mija Jackson Lee, PLLC 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.
By submitting this form and typing your name above you are electronically signing this form.