✉ Contact Us
Book Appointment Westminster
Book Appointment Orange
130 S Main Street Suite F,
Orange, CA 92868
📱
(714) 939-2020
15068 Goldenwest Street,
Westminster, CA 92683
📱
(714) 898-5631
ABOUT US
WHY CHOOSE US
OUR DOCTORS
HOURS & LOCATION
INSURANCE
ORANGE REVIEWS
WESTMINSTER REVIEWS
Eye Care
EYE EXAMS
COMPUTER VISION
DRY EYES
LASIK MANAGEMENT
EYEWEAR
CONTACT LENSES
FRAME BRANDS
EYEGLASS LENS OPTIONS
BLUE LIGHT LENSES
PATIENT INFO
PATIENT FORMS
EDUCATION
BLOG
Emergency
Emergencia
COVID-19 Screening Questionnaire
Office
Dr. Bass Vision Center Orange
Dr. Bass Vision Center Westminster
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
Dr. Bass Vision Centers
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
Yes
No
Difficulty breathing or shortness of breath
Yes
No
Cough
Yes
No
Sore throat/trouble swallowing
Yes
No
Runny nose/stuffy nose or nasal congestion
Yes
No
Decrease or loss of smell or taste
Yes
No
Nausea, vomiting, diarrhea, abdominal pain
Yes
No
Not feeling well, extreme tiredness, sore muscles
Yes
No
2. Have you traveled outside of the country in the past 14 days?
Yes
No
3. Have you had close contact with a confirmed or probable case of COVID-19?
Yes
No
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)
ORANGE
130 S Main St Suite F
Orange, CA 92868
(714) 939-2020
Map It
Office Hours
Email Us
Book Appointment
WESTMINSTER
15068 Goldenwest Street
Westminster, CA 92683
(714) 898-5631
Map It
Office Hours
Email Us
Book Appointment
Dr. Bass Vision Center Orange
130 S Main Street Suite F
Orange
,
CA
92868
Phone:
(714) 939-2020
Fax:
(714) 939-0356
Dr. Bass Vision Center Westminster 15068 Goldenwest Street Westminster, CA 92683 Phone: (714) 898-5631 Fax: (714) 898-4771
© 2022 All content is the property of
Dr. Bass Vision Centers
™ & assoc. vendors. |
DISCLAIMER
|
HIPAA
Website Powered and Developed by
EyeVertise.com
Internal Access Only