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We are located on the corner of Spring Cypress and Champion Forest, in the Stables Town (Kroger) Shopping Center near Subway and Pizza Hut.

Call Us 281-655-9595

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Eye Doctors
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Insurance
Patient Forms

Home » Patient Screening Form

Patient Screening Form

Name*
First Last
Date of Birth
MM slash DD slash YYYY
Phone*
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*
- Yes
- No
Are you/they experiencing shortness of breath or other difficulties breathing?*
- Yes
- No
Do you/they have a cough or a sore throat?*
- Yes
- No
Any other flu-like symptoms, such as gastrointestinal upset, nausea, diarrhea, headache or fatigue?*
- Yes
- No
Have you/they experienced recent loss of taste or smell?*
- Yes
- No
Are you/they in contact with any confirmed COVID-19 positive patients?*
- Yes
- No
• Patients who are well but who have a sick family member at home with COVID-19 should consider postponing office visit.
Have you/they traveled outside the country in the past 14-21 days?*
- Yes
- No
Positive responses to any of these would likely indicate that your appointment will be postponed
PATIENT/LEGAL GUARDIAN SIGNATURE*
Date
MM slash DD slash YYYY

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Urban Eyes Inc

8765 Spring Cypress Rd, Ste N
Spring, TX 77379

Phone: 281-655-9595
Email: urbaneyes@urbaneyes.com
(Do not send personal health information by email.)

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: Closed
Thursday: 9:00 AM - 5:00 PM
Friday: 9:00 AM - 5:00 PM
Saturday: 9:00 AM - 1:00 PM
Sunday: Closed

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Hours & Location
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Eyeglasses
Contact Lenses
Insurance
Patient Forms

Hours & Location
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Contact Lenses
Insurance
Patient Forms

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Urban Eyes Inc - Located at 8765 Spring Cypress Rd, Ste N, Spring, TX , 77379. Phone: 281-655-9595 . https://www.urbaneyes.com

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