COVID Screening Questions

Please fill out the form below and click submit to fill out our COVID-19 Screening form.

Have you experienced any of the following symptoms in the past 48 hours:

Have you experienced any of the above listed symptoms in the past 48 hours: *

Have you or anyone in your household tested positive for COVID 19 in the past 14 days? *

Have you or anyone in your household been in contact with anyone who tested positive for COVID-19 in the past 14 days? *

Are you currently waiting on the results of a COVID-19 test? *

Have you traveled outside the US in the past 14 days? *

Have you had the COVID-19 Vaccine (both doses)? *

Today's Date

Name*

Patient's Signature*

Phone *

Please do not submit any Protected Health Information (PHI).

Monday

8:30 am - 12:00 pm

1:00 pm - 4:30 pm

Tuesday

8:30 am - 12:00 pm

1:00 pm - 6:00 pm

Wednesday

8:30 am - 12:00 pm

1:00 pm - 6:00 pm

Thursday

8:30 am - 12:00 pm

1:00 pm - 4:30 pm

Friday

8:30 am - 12:00 pm

PM Closed

Saturday

Closed

Sunday

Closed

--mi

Griswold Eye Care

Address

8 N Main St
Jewett City, CT 06351

Contact Information (860) 376-2848

(860) 376-4821

8 N Main St
Jewett City, CT 06351