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Fairway Focus
FAIRWAY 913-362-2323
LEAWOOD 913-491-9123
LIBERTY 816-781-5444
RAYTOWN 816-313-5060
FAIRWAY
LEAWOOD
LIBERTY
RAYTOWN
Covid Screening
Please answer these additional questions to help ensure the safety of our patients and staff.
Name
*
First
Last
Date of Birth
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Fairway, Kansas
Leawood, Kansas
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Raytown, Missouri
Are you currently experiencing any:
Coughing
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Shortness of breath
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No
Fever
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Yes
No
Chest pain or tightness
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Yes
No
Have you traveled out of state in the last 14 days?
*
Yes
No
Have you been in contact with anyone who has traveled out of state in the last 14 days?
*
Yes
No
Have you tested positive for COVID-19 in the last 14 days?
*
Yes
No
Have you been in contact with anyone that has tested positive for COVID-19 in the last 14 days?
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No
Reason for your visit and/or additional information
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BEST EYE CLINIC 2019
PITCH BEST OF KC