COVID-19 Patient Safe Entry Form 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: Fever within the past 48 hours. Symptoms of Fatigue, Muscle aches or Respiratory Distress in the past week. Exposure to anyone that tested positive for COVID-19 in the past 2 weeks. Print Name* First Last Date* MM slash DD slash YYYY Signature*
