COVID-19 Patient Safe Entry Form

Name: Maison Optique Vision Center
Address: 3810 Ambassador Caffery Parkway, Suite 700, Lafayette, LA, 70503, US
Price range: $000 - $300

Maison Optique Vision Center has put protocols in place for the safety of our patients and staff. Please sign below confirming that you have notexperienced any of the following:
1. Fever within the past 48 hours.
2. Symptoms of Fatigue, Muscle aches or Respiratory Distress in the past week.
3. Exposure to anyone that tested positive for COVID-19 in the past 2 weeks.
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Date*
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