5 Convienent Locations!

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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 Master Eye Associates TN

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)

- 5 Convenient Locations -

Olive Branch

5218 Goodman Rd
Olive Branch, MS 38654
☎ (662) 269-6305
📱Text Us

- Hours -
Mon-Fri: 10am-6pm
Sat: 10am-4pm

Poplar Commons

4562 Poplar Ave #115
Memphis, TN 38117
☎ (901) 683-1796
📱Text Us

- Hours -
Mon-Fri: 9am-6pm
Sat: 9am-4pm

Southaven

338 Goodman Rd W
Southaven, MS 38671
☎ (662) 510-7397
📱Text Us

- Hours -
Mon-Fri: 9am-6pm
Sat: 9am-4pm

Winchester

7706 Winchester Rd. #105
Memphis, TN 38125
☎ (901) 752-1551
📱Text Us

- Hours -
Mon-Fri: 9am-6pm
Sat: 9am-4pm

Wolf Creek

2825 N. Germantown Parkway #103
Memphis, TN 38133
☎ (901) 384-9259
📱Text Us

- Hours -
Mon-Fri: 9am-6pm
Sat: 9am-4pm

Master Eye Associates - Olive Branch 5218 Goodman Rd Olive Branch, MS 38654 Phone: Coming Soon

Master Eye Associates - Poplar Commons Poplar Commons 4562 Poplar Ave #115 Memphis, TN 38117 Phone: (901) 683-1796 Fax: (901) 683-1603

Master Eye Associates - Southaven 338 Goodman Rd W Southaven, MS 38671 Phone: (662) 510-7397 Fax: 9662) 598-4280

Master Eye Associates - Winchester 7706 Winchester Rd. #105 Memphis, TN 38125 Phone: (901) 752-1551 Fax: (901) 752-1505

Master Eye Associates - Wolfcreek 2825 N. Germantown Parkway #103 Memphis, TN 38133 Phone: (901) 384-9259 Fax: (901) 385-7592

Master Eye Associates proudly serves Memphis, TN and the surrounding areas of Cordova, Collierville, Southaven, Bartlett, Germantown, Olive Branch, Byhalia, Horn lake and West Memphis.