2115 S. Hacienda BLVD.
Hacienda Heights, CA 91745
Call (626) 330-4115 or text us

500 N. Atlantic Blvd. Unit 151
Monterey Park, CA 91754
Call (626) 458-2020 or text us

COVID-19 Screening Questionnaire

Office

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 Focus 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)

Email Us

Text Hacienda Heights

Text Monterey Park

2115 S. HACIENDA BLVD.
HACIENDA HEIGHTS, CA 91745
Call (626) 330-4115
Map it!

Mon

9:00 - 6:00

Tue

9:00 - 6:00

Wed

9:00 - 6:00

Thu

Closed

Fri

9:00 - 6:00

Sat

9:00 - 5:00

Sun

Closed

500 N. ATLANTIC BLVD. UNIT 151
MONTEREY PARK, CA 91754
Call (626) 458-2020
Map it!

Mon

10:00 - 5:00

Tue

10:00 - 5:00

Wed

10:00 - 5:00

Thu

10:00 - 5:00

Fri

10:00 - 5:00

Sat

Closed

Sun

Closed

Hacienda Heights Office 21115 S. Hacienda BLVD Hacienda Heights, CA 91745 Phone:

Monterey Park Office 500 N. Atlantic Blvd. Unit 151 Monterey Park, CA 91754 Phone:

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