Fill out your medical history prior to your appointment!

Please read the following information below, you will be asked to sign the Release Form at the office before your evaluation.

What is Expected/Required For Your Eye Exam During COVID-19 at Forest Family Eye Care

 

  1. Prior to your visit, we ask that you complete the online medical history information requested through email sent by the office prior to your exam.

  2. When you arrive to your scheduled exam, please remain in your car and call the office at 434-385-7898 to check in

  3. All patients must bring and wear a face mask while in the office for the exam. Patients who do not have a mask can purchase one from us for $2.00.

  4. Please leave your cellular phone in the car or turned off in purse/pocket while in the office. Touching your phone increases chances of transferring virus particles from outside of the office

  5. A staff member will call or signal for you to enter the office at the appropriate time. Upon entering the office, we will ask that you stop in the waiting room to have your temperature taken and be screened. Please do not move past the waiting room.

  6. After being screened, we will ask that you wash your hands in the restroom and approach the front desk (marked on the floor with an X) to read and fill out paperwork including a release form

  7. After forms are completed, the technician will begin pre-testing to prepare you to see the doctor.

  8. Between patients the exam rooms, equipment, and handheld tools will be sanitized with alcohol. During the exam the doctor will attempt to limit close contact as much as possible. We will also be offering discounted retinal photography in order to speed up retinal examination.

Patient Release Form for the COVID-19 Virus

I, ____________________________________(“the Patient”), do hereby request an eye examination from Forest Family Eye Care. I understand that I could postpone or cancel this visit without any penalty due to the prevalence of the virus, but feel I need to be examined at this time because:

_____________________________________________________________

____________________________________________________________.

With my signature below I certify that I have no symptoms of the virus; temperature, coughing, shortness of breath, etc., and that I have not knowingly been in contact with anyone having those symptoms associated with the virus or anyone who is a COVID-19 suspect or anyone diagnosed with COVID-19 in the past 2 weeks.

In an effort to reduce exposure for both the Doctor and the patient, we are recommending retinal photos. During this time, we are discounting the cost of the photos by 50% to $19.00. We strongly urge all patients to do this but if finances do not allow, please initial here: __________________

The Patient understands the potential risks of being examined and inadvertently exposed to the virus. The patient agrees to hold Forest Family Eye Care, its owners, and employees, (“FFEC”) harmless if I should develop symptoms or contract the disease after this visit. The Patient expressly waives any such claim for compensation or liability on the part of FFEC should the Patient contract the disease. The Patient, for itself and its heirs, executors, administrators and assigns, hereby release, waive, discharge and hold harmless FFEC from any and all liability, claim and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise in the event the patient contracts the disease. The Patient understands and acknowledges that this Release Form discharges FFEC from any liability or claim that the Patient may have against FFEC with respect to, including but not limited to: bodily injury, personal injury, illness, disability, death, or any other claim that may result from the services in relation to contracting the virus. This release is intended to discharge, in advance, FFEC from any and all liability arising out of or connected in any way with the performance of work or services or provisions of materials, even though that liability may arise out of negligence or carelessness on the part of FFEC.

The Patient expressly agrees that this Release Form is intended to be as broad and inclusive as permitted by the laws of the State of Virginia and that this Release Form shall be governed by and interpreted in accordance with the laws of the State of Virginia.

By signing below, the patient certifies the above statements as true and agrees that he/she has been given the opportunity to ask questions and fully understands its intent and enters into this Release Form agreement willingly and voluntarily.

 ___________________________________          _____________               

Signature of the Patient                                              Date                         

Initials of FFEC employee   _______                       Temperature at time of visit: ______ 

Existing patients, please use this feature to let us know if there has been any change in your medical history. Your password is your hyphenated SSN, ex. 123-45-6789. If this doesn't work, just use the "New Patient Page".

New Patients click the "New Patient Page".

Medications and allergies will be noted at the time of service. 

©2020 by Forest Family Eye Care.

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