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1601 Willow Lawn Drive, Suite 254, Richmond, VA 23230
Home » Contact Us » COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form

COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form

  • Please Note: All fields are required and must be completed before the form can be submitted.
  • Date Format: MM slash DD slash YYYY
  • Please read the following statements and answer yes or no next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.
  • Do you, your child, others accompanying you to today's appointment have any of the following symptoms?
  • Public Health Reminder

  • Healthcare facilities and clinicians should prioritize urgent/emergency visits and procedures now and for the coming several weeks. The following actions can preserve staff members, personal protective equipment and patient care supplies.
  • By signing this form below, I agree that I will not hold Dr. Kristine-Hue Van & Associates, Inc. or any of its doctors or staff members personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosis with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for any personal illness that may result and further release and discharge Dr. Kristine-Hue Van & Associates, Inc. and its doctors and staff members for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.
  • Date Format: MM slash DD slash YYYY
  • **Please note that all patients will be screened over the phone and upon arrival for COVID-19 related questions. You will be required to wear a mask and have your temperature taken. We ask all patients to adhere to the social distancing requirement of 6 feet apart and we will permit no more than 10 people in our office space at a time. All patient will be required to fill out check-in forms online ahead of time to limit the amount of exposure time in the office. All forms of payments are due and expected at time of service. Only the patient is allowed in the facility unless the patient is a minor or requires additional assistance by a caretaker or a family member.
  • This field is for validation purposes and should be left unchanged.
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COVID Updates

The safety of our patients and staff is our top concern. Dr. Kristine-Hue Van & Associates, Inc. has always followed universal precaution procedures and we continue to follow strict disinfection protocols. Please click here to read what to expect at your next appointment.