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 Flatbush Optical

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)
Enter Letters/Number you see:



1594 Flatbush Avenue
Brooklyn, NY 11210
(718) 434-0539
HOURS OF OPERATION    
Monday
10:00am - 6:00pm
Tuesday
10:00am - 6:00pm
Wednesday
10:00am - 6:00pm
Thursday
10:00am - 6:00pm
Friday
10:00am - 6:00pm
Saturday
10:00am - 5:00pm
Sunday
Closed
2011 Church Avenue
Brooklyn, NY 11226
(718) 469-3311
HOURS OF OPERATION    
Monday
10:00am - 6:00pm
Tuesday
10:00am - 6:00pm
Wednesday
10:00am - 6:00pm
Thursday
10:00am - 6:00pm
Friday
10:00am - 6:00pm
Saturday
10:00am - 5:00pm
Sunday
Closed
11122 Flatlands Avenue
Brooklyn, NY 11207
(718) 257-9393
HOURS OF OPERATION    
Monday
10:00am - 6:00pm
Tuesday
10:00am - 6:00pm
Wednesday
10:00am - 6:00pm
Thursday
10:00am - 6:00pm
Friday
10:00am - 6:00pm
Saturday
10:00am - 5:00pm
Sunday
Closed
Flatbush Avenue 1594 Flatbush Ave Brooklyn, NY 11210 Phone: (718) 434-0539 Fax: (718) 434-0677
Church Avenue 2011 Church Avenue Brooklyn, NY 11226 Phone: (718) 469-3311 Fax: (718) 928-7262
Flatlands Ave 11122 Flatlands Ave Brooklyn, NY 11207 Phone: (718) 257-9393

Flatbush Optical has three locations in Brooklyn, Serving the neighborhoods of East Flatbush, Prospect Park South, Mapleton, Brownsville, Crown Heights, Flatlands, Mill Basin, Bergen Beach, and Garrison Beach.

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