0%Eye Interview
  • COVID-19 Treatment Consent Form

    I consent to receive treatment from the eye gallery during the COVID-19 outbreak.
    I understand there is much to learn about the newly emerged COVID-19 including how it spreads and transmitted.
    I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19.
    I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.
    I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the procedures performed here, that I have an increased risk of contracting the virus by being in the practice and by receiving treatment in the practice.



    I understand that the symptoms listed below are representative of COVID-19:
    ● Fever
    ● Dry Cough
    ● Shortness of Breath
    ● Temperature
    ● Persistent pain or pressure in the chest
    ● Bluish lips or face

    I confirm that I do not display or currently have any of the symptoms that are representative of COVID-19, which are outlined above.

    I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.
  • Welcome,

    This pre-examination interview is highly valued by Dr. Bulos and his staff.

    Please answer every question honeslty, just as you would in person.

    Your answers will be clarified during your examination.

    Thank you.
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  • Please tell us about your current corrective lenses.

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    If you wear contact lenses please complete this section.
    If not.. go to next page.

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