1235 S. CENTER RD, #16
BURTON, MI 48509
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(810) 744-1950

523 M.L. KING AVE.
FLINT, MI 48502
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(810) 238-0925

3140 SILVER LAKE RD
FENTON, MI 48430
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(810) 593-1000

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 General 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)

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Request An Appointment

1235 S. CENTER RD #16
BURTON, MI 48509
Map it | Hours
(810) 744-1950

523 M.L. KING AVE.
FLINT, MI 48502
Map It | Hours
(810) 238-0925

3140 SILVER LAKE RD
FENTON, MI 48430
Map it | Hours
(810) 593-1000

Burton Office 1235 S. Center Rd. #16 Burton, MI 48509 Phone: (810) 744-1950 Fax: (810) 744-1515

Fenton Office 3140 Silver Lake Rd Fenton, MI 48430 Phone: (810) 593-1000 Fax: (810) 593-1113

Flint Office 523 M.L. King Ave. Flint, MI 48502 Phone: (810) 238-0925 Fax: (810) 238-2174

General Optical proudly serves Flint, MI and the surrounding areas of Burton, Fenton, Grand Blanc, Swartz Creek, Davison, Atlas, Goodrich, Holly, Linden, Genesee, Mt. Morris and Flushing.

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