Honolulu Vision Care Center: COVID-19 Health Declaration

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Please complete this brief questionnaire to help protect our patients, staff, and doctors from COVID-19 exposure.

***Your response is required BEFORE your scheduled office visit***

If you have any questions, please visit https://www.honoluluvision.com/coronavirus or call 808-396-6311. Thank you for helping to keep everyone safe.

Patient Full Legal Name *

Patient Email Address *

Please provide the best email address if we need to reach you regarding your responses.

Patient Phone Number *

Please provide the best contact number if we need to reach you regarding your responses.

Appointment Date

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