Read Before Signing:
I have read the health questions above and have answered them honestly and to the best of my knowledge. I
understand that North Garland Vision, its doctors and staff are taking precautions to limit any potential exposure I
may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate potential exposure
by one hundred percent.
By signing this form below, I agree that I will not hold North Garland Vision or any of its doctors or staff personally
responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed
with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I
assume full responsibility for personal illness that may result and further release and discharge North Garland
Vision and its doctors and staff for injury, loss or damage arising out of my visit. I understand that COVID-19
infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye
exam to be essential to the maintenance of my vision.
I, the undersigned, affirm that I am at least 18 years of age and am freely signing this agreement or that I am
signing on behalf of a minor child that I have the legal authority to sign such agreements on behalf of. I have
read this form and fully understand it.