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COVID Questionnaire

Eyes in the Village is dedicated to serving you for your eye care needs while ensuring we operate in the safest manner for all of our patients and staff during this difficult time. Please read and acknowledge the following statements: 

  • I have not traveled or returned from outside Manitoba in the past 14 days. Exceptions are made for residents of Nunavut that are following provincial health guidelines. 
  • I am not under direction to self-monitor or self-isolate 
  • I am not experiencing any of the following NEW or WORSENING symptoms that are not related to chronic conditions or other known causes.
    • Fever or Chills 
    • Decrease or Loss of Smell or Taste 
    • Difficulty Breathing or Shortness of Breath 
    • Cough - Runny Nose, Stuffy Nose or Nasal Congestion 
    • Extreme Fatigue, Sore Muscles 
    • Nausea, Vomiting, Diarrhea, Abdominal Pain 
    • Sore throat, Trouble Swallowing 
  • I acknowledge that if ANY of the above statements are untrue for myself, I must reschedule my visit for a later date. 
  • I understand that I MUST wear a mask during the entire duration of my stay at Eyes in the Village. I understand that I am responsible for bringing my own mask to the appointment or one will be provided to me at a cost of $2.00. 
  • I agree to come alone to my appointment and that no additional people will be allowed in the waiting room or to help with frame selections at this time. Exceptions can be made for 1 parent with a child as well as any individual needing medical assistance, HOWEVER, we must be aware of this prior to appointment to make accommodations in other areas to limit numbers. 
  • I understand that frame repairs for glasses past warranty or frames purchased elsewhere will be subject to a repair fee. 
  • I understand that Eyes in the Village will validate my parking in our lot but I am responsible for giving my license plate # to reception UPON ENTRY to the clinic to be entered into the online database. Failure to do so may result in a parking ticket that is unfortunately out of our hands. 
Your Name(Required)
Sign by entering your name.
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